Inspection on 10/12/05 for Gwendoline House

This inspection was carried out on 10th December 2005.

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

Gwendoline House 29/08/07

Gwendoline House 09/02/07

Gwendoline House 28/02/06

Gwendoline House 31/05/05

Gwendoline House 14/06/04

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

CARE HOMES FOR OLDER PEOPLE Gwendoline House 17-19 Pleasant Road Staple Hill South Glos BS16 5JN Lead Inspector Odette Coveney Unannounced Inspection 09:30 10 December 2005 th 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 Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 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. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gwendoline House Address 17-19 Pleasant Road Staple Hill South Glos BS16 5JN 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) 0117 9571957 0117 9571957 Mr Philip Frederick Moss Mrs Moira Ann Moss Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 16 persons aged 65 years and over requiring personal care only 31st May 2005 Date of last inspection Brief Description of the Service: Gwendoline House is a privately owned care home for older people situated in Staple Hill, a residential area of Bristol. It is close to local shops and a bus route. Gwendoline House is a detached property with three floors. The proprietor, Mr Moss, lives and works full time at the home, taking overall responsibility. He concentrates his time mainly on cooking and paperwork tasks. Mrs Moss is the registered manager and is significantly supported by the senior member of staff, Marian Vargheese who currently provides the main management of care to the service users. The property has been extended to provide space for sixteen service users. The communal areas comprise a lounge, dining room and conservatory. All bedrooms are single occupancy and thirteen have en-suite facilities. In addition there are three toilets, two shower rooms and a bathroom. There is a secluded courtyard garden with seating, potted plants and a water feature. There is a warm and cheerful atmosphere in the home and activities are organised on a regular basis. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process to examine the care provided and monitor the progress in relation to the two recommendations from the last inspection that was conducted in May 2005. During this inspection any standards, which were not reviewed at the previous inspection, were examined, these included: the statement of purpose, meeting identified needs, trial periods, health and personal care, legal rights, facilities and staff induction and supervision. The inspection took place over six hours. During the process ten residents, two staff, visitors and the deputy manager were spoken with. The inspector looked around the building and a number of records were examined. Following consultation with the manager and those living at the home it was agreed that those at the home would prefer to be referred to as resident’s within the inspection report, rather than service user and therefore this has been reflected within this report. The Commission for Social Care Inspection has produced a leaflet for those living in care establishments entitled ‘Is the care you need the care you get?’; a copy of this was left at the home to be put on the home’s notice board. What the service does well: Gwendoline House is a residential care home for sixteen older people, the home is comfortable, cosy and very homely. Gwendoline House is very much ‘home’ to those who are living there, the furnishings and environment are comfortable, the home and the garden are maintained to a high standard. All of the staff have created a comfortable and homely environment in which residents feel secure. There is a low staff turnover and residents can therefore be confident that they will receive support from people they know. It was clearly evident that the manager and the staff team are committed to ensuring that all of the needs of individuals at the home are met, this is done through consultation and observation and previous knowledge and an understanding of individuals through a person centred individualised process. All of the resident’s spoken with and also visitors to the home were very complimentary about the care and attention individuals receive at the home. Comments made included:’ ‘nothing is too much trouble for the staff’, ‘there is always a lovely atmosphere here and people are well cared for’ ‘lovely staff, lovely food, lovely home, nothing more to say, says it all!’ Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 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 Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 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): 1, 2, 3, 4, 5 Prospective resident’s and those living at Gwendoline House have clear information about the facilities and services which are provided at the home and can be assured that following clear admission processes their needs will be met. Clear contractual arrangements are in place. EVIDENCE: The home has recently updated and revised both the statement of purpose and the brochure. The statement of purpose was detailed and fully outlined the rights of resident’s and the responsibilities of the management and staff employed at the home in order that the aims of the home are met. Information contained within the statement of purpose includes the organisational structure, management and staffing arrangements. There is also information about the admissions process and whom the home is able to care for. Information within this document outlines how each person’s needs, both from a holistic and individual perspective will be met, recorded and reviewed and updated when needed. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 9 The reviewed brochure for the home has been enhanced by the use of photographs and provides confirmation of individual’s choices and wishes, it records that resident’s will be consulted and listened to. The aim of the home as recorded in the brochure is ‘To enable our resident’s to maintain their dignity, independence and to encourage continuing interests, hobbies and social activities whilst living in a supportive family atmosphere’. Visitors to the home gave many examples of why they consider Gwendoline House a good home for their relative, comments given were; ‘staff are always polite caring and very patient’, ‘the food here is delicious’. The inspector saw that clear contracts for those living at the home are in place the information held within these includes the room to be occupied, overall care and services covered by the fee, fees payable and by whom, rights and obligations of the residents and the registered provider and terms and conditions of occupancy including notice periods. Information seen in care records such as pre-admission assessment, admissions questionnaire and the views of the resident’s confirmed that new residents are only admitted to the home on the basis of a full assessment undertaken by people who are trained to do so. Those residents who have been referred through the care management process had in place a copy of the care manager’s assessment and care plan. For those who are privately funded they had in place a fully detailed care plan and an assessment of need which further demonstrated that the home was able to meet their needs. The deputy manager confirmed information seen within the homes admission process that individual’s are invited to look around the home prior to admission and are able to stay for a meal and to meet other residents and staff in order to determine if the home is able to meet their needs. The deputy manager confirmed that individual’s are admitted to the home for a months trial in order that a fuller picture of the services provided can be made and also in order for the home to undertake further assessment of need. The deputy manager said that there have been occasions where the trial period has been extended in order to ensure the placement is the appropriate one. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 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, 11 Care plans are well written, reviewed and updated on a regular basis. Health needs of individuals are met, further information is needed outlining the needs and wishes of resident’s in the event of their death. EVIDENCE: It was noted that at the previous inspection the home scored 4 in respect of the care planning information held at the home, this score will remain as it was evident that standards of record keeping have been well maintained at the home and are above the requirements of the National Minimum Standards. Care plans are in place for all resident’s who live at the home, with four resident records being reviewed at this inspection. Care plans are written in a person centred way with full information contained within the plan in order to guide and direct staff. The plan covers areas such as communication, mobility, personal care support, and significant relationships, social, emotional needs, health support and personal safety. Each person had recorded within care records their preferred daily routine; these covered each day of the week, mornings, afternoon and nighttimes. Care plans are reviewed and updated where required on a monthly basis. Well-written care plan reviews were in place. The home undertakes these care plan/placement reviews every six months with the resident fully involved, it is good practice to see that Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 11 resident’s had signed their care plan review notes to evidence they had read and agreed with the contents. The deputy manager was able to give detailed information about the physical support, care, emotional and healthcare needs of those living at the home. She was fully conversant with residents changing needs and areas of their life, which are important to them and how the home can ensure that these needs are met. The deputy manager promotes and maintains resident’s health and ensures access to health care services to meet assessed needs. Opportunities are provided for appropriate exercise and physical activity. Manual handling risk assessments were in place for residents incorporating the risk of falls, all had been reviewed within the past few months. All of the resident’s are registered with a general practitioner; those residents who wanted them have received vaccinations against influenza and phuenomnia. Resident’s have accessed hearing, sight tests and appropriate aids according to their need. Systems of medication administration and recording were not reviewed at this inspection as this standard was reviewed at the last inspected and systems in place exceed the National Minimum Standards. These standards will be reviewed at the next inspection. There is no information in place to demonstrate that resident’s wishes concerning terminal care and arrangements after death have been discussed. It is recommended that the home seeks ways of obtaining and recording the views of residents in the event of their death in order to ensure that individual’s wishes are respected. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 Resident’s lifestyle at the home matches their expectations and preferences, individuals are supported to maintain important relationships and to participate in activities of their choice. EVIDENCE: During the inspection one of the resident’s walked to the local shop to get their daily paper, they said they enjoyed their daily visit that provided them an opportunity to exercise and socialise. Another lady went out to visit a local church group, other residents told the inspector about the variety of entertainment that takes place at the home, such as piano sing-along and gentle exercise. Resident’s spoken with were in particular looking forward to a carol service taking place the next day with members of the local church. Posters were on display at the home advertising forthcoming social events, family and friends were also invited to attend. The deputy manager said that resident’s are supported to participate in activities of their ability and choice. Within the home’s brochure and statement of purpose is information on how individual’s social activities, hobbies and interests will be maintained. The home has spent time with individuals gathering information on people’s previous interests and hobbies and care records and discussion with resident’s Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 13 confirmed that these have been maintained where individuals ability and health has enabled. It is recorded in the home’s statement of purpose that it is staff member’s duty to respect the rights of residents. The deputy manager confirmed that rights of individuals are respected, an example given was that residents are able to make choices on activities of daily living, their routines and within their rights as citizens. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Resident’s can be confident that complaints will be listened to and acted upon. Resident’s legal rights are protected and suitable arrangements are in place to protect residents. EVIDENCE: A copy of the home’s complaints procedure was on prominent display at the home. Information on how individuals are able to raise issues or make a complaint was seen in individual licence agreements, with information including the arrangements for contacting the Commission if individuals were not happy with the outcome of a complaint, this requires updating to reflect the change from the National Care Standards Commission to the Commission for Social Care Inspection. The complaints logbook for the home was viewed; it was found that reported incidents had been dealt with effectively to the satisfaction of those involved. The last recorded complaint was in November 2005, this was in respect of noise. The logbook identifies and records both formal and informal complaints, which is consistent with good practice. No staff at the home are on the protection of vulnerable adults list. No areas of concern were recorded on care documentation. All of those spoken with during the inspection were positive about the care they receive and said they were happy with no complaints or concerns raised to the inspector. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 15 The deputy manager feels that relationships built on trust and honesty have been established at the home and that residents often spend time in the office and are given the opportunity to discuss any areas of concern they may have. The home has in place a copy of the South Gloucestershire Social Services Protection of Vulnerable Adults Policy. The home has a clear complaint procedure which records that the home operates a ‘no blame policy so that any complaint allows full thorough and open investigation’. Complements are also well recorded at the home. Staff have undertaken protection of vulnerable adults training, the deputy manager explained what this training had included and the benefits of undertaking this. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 16 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, 20, 21, 23, 24, 25, 26 The home is well managed and safe and the quality of furnishings and fittings in the home is good, providing a warm comfortable and homely environment ensuring individuals needs are met. EVIDENCE: The home is comfortable and homely with an array of pictures, plants and soft furnishing which enhance the environment for those who live at Gwendoline House. There is a cosy lounge where most of the residents had chosen to sit and there is a pleasant dining room and a sun lounge for resident’s to enjoy. There were sufficient toilet, bathrooms and showering facilities for residents use. Most of the resident’s rooms have en-suite facilities, one with a bath others with toilet and a hand basin. Since the last inspection the home has purchased two new washing machines and a tumble dryer. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 17 It was noted at the previous inspection that a bath panel required some attention to ensure residents did not injure themselves. The inspector saw that this has been replaced. An immediate requirement was made at the last inspection that radiators must be guarded and that risk assessments put in place for the safety of residents. This requirement had been met, those radiators identified at the last inspection have been guarded and all resident’s have in place a risk assessment incorporating radiators in individual’s rooms. A hand test of the water temperature found the temperature was not excessive and was at a safe level, the temperature in the home was warm and comfortable. Water temperatures are checked three times per week. At the time of the inspection all areas seen were clean, tidy and odour free. All of those living at the home have access to their personal and communal space. The home has a very pleasant rear patio garden; this was seen to be well tended. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 18 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, 30 There is a stable, competent staff team at the home who have been appropriately recruited, supervised and trained. EVIDENCE: There is a full complement of staff working at the home, with the last staff member being taken on in March 2005. This staff member told the inspector that they are happy at the home, they feel well supported and ‘it’s fantastic working here’. The manager was asked to explain the recruitment process for the home, the information given, in conjunction with documents seen in staff files confirmed that staff are employed following robust recruitment and selection. In place were references from the most recent employer, criminal records and protection of vulnerable adults check. Job descriptions record the duties and responsibilities of staff that they are to enable, encourage and support residents to make choices. Contracts were in place for staff which had been signed and dated by staff, this document included terms and conditions of employment, equal opportunities, disciplinary and grievance procedure. It is recommended that staff contracts included staff responsibility in the event of committing an offence and notification of this if this occurred during their employment at the home. Staff are supervised on a daily basis informally, formally staff receive one to one support meetings on a regular basis. Records of these supervisions Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 19 showed that appropriate subjects were discussed to ensure the needs of those living at the home are met. Staff training and development with action plans are in place. Staff are given supervision agreement, which outline the responsibilities of the supervisee and supervisor including the practical arrangements for supervision and the importance of confidentiality. Induction for staff is fully comprehensive. The deputy manager has recently attended a meeting with a local independent training provider to discuss the new skills for care induction programme. The deputy manager said that following this meeting she will be revising their existing induction programme to include the new requirements, these include new staff members having an understanding and support in areas of numeracy and literacy. The deputy manager came across as very supportive and encouraging to staff and said that ‘staff should feel privileged to work here’ ‘this is the resident’s home’ Many favourable comments were received about staff at the home, staff members were also named and praised by those living at the home, and these comments were shared with the deputy manager. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 20 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, 36, 37, 38 There is a sound management team at the home with the registered manager being able to discharge their responsibilities fully. Individuals live in a safe environment run in their best interests. EVIDENCE: Mr and Mrs Moss are the registered providers who have been the owners of the home since it originally opened over twenty years ago. Mrs Moss has been unwell for sometime but has been making a recovery and has recently returned to manage the home on a part time basis. It was noted at the previous inspection that Mrs Moss holds a pivotal role within the home and has commenced her National Vocational Qualification; progress in this area will be further reviewed at the next inspection. Marion Varghesse has been ‘acting up’ as the manager and has achieved her registered managers award and a National Vocational Qualification at level four in care management. Ms Varghesse is a qualified nurse and undertakes fives days training per year in order to maintain her PREP (Post Registration Education Portfolio). All of those Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 21 spoken with during the inspection were full of praise for Marian and spoke of her kindness and patience. Evidence was in place to demonstrate that the home has ensured as far as is reasonably practicable the health and safety of those who live in, work at and visit the home. The fire logbook showed that weekly checks are completed, however the monthly required checks of the emergency lighting had not been recorded. The deputy manager said that emergency lighting is checked for safety when other monthly checks in respect of fire safety are undertaken. It is required that these lighting checks must be recorded to demonstrate that they have been completed. The home has in place a fully comprehensive fire risk assessment, this covers the identification of hazards, who is at risk, actions taken to eliminate/reduce risk. It is recommended that this assessment is dated in order to demonstrate that this is regularly reviewed. The home’s fire policies and procedures in respect of fire were well written and included a clear night procedure should a fire occur at this time. All staff have received appropriate and sufficient fire instruction, which has included participation in fire drills, discussion, fire videos and questionnaires to ensure staff understanding of their responsibility in this area. The home has purchased a pack which incorporates policies and procedures which are required for those who provide a care service; those seen included; the management of health and safety at work, staff disciplinary and competency procedures, receiving gifts, clinical waste and missing persons procedure. These provide information to staff in order to ensure compliance and consistency. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 22 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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 2 Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 23 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 OP38 Regulation 23(4) Requirement Emergency lighting must be recorded. Timescale for action 12/12/05 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 Refer to Standard OP38 OP29 OP11 Good Practice Recommendations The home’s fire risk assessment to be dated. Consideration to be given for staff contracts to include notification of criminal offence during their employment. The home is to seek and record the wishes of residents in the event of their death. Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Gwendoline House DS0000003325.V254369.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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