CARE HOMES FOR OLDER PEOPLE
Harbour House Penberthy Road Portreath Redruth Cornwall TR16 4LW Lead Inspector
-Paul Freeman Announced Inspection 3rd October 2005 10:30 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 Harbour House DS0000053837.V258533.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. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Harbour House Address Penberthy Road Portreath Redruth Cornwall TR16 4LW 01209 843276 01209 843276 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) Mrs Mary Allison Anson Mr John Robert Anson Sarah Joanne Eustice Care Home 18 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (18) of places Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Service users to include up to 5 adults aged over 65 with dementia (DE(E)) To accommodate one named service user outside the registered categories of the home To accommodate one named service user outside the registered categories of the home Total number of service users not to exceed a maximum of 18 Date of last inspection 3rd May 2005 Brief Description of the Service: Harbour House cares for 18 older people and is a two story detached property that has been extended and stands in its own grounds close to the harbour. It is set in a residentail area near to local amenites and a reliable bus service providing access to local towns. There is disability access on the ground floor and three lifts are provided internally. One is a full shaft lift, the second a stair lift providing access to the bedrooms on the first floor and a third upstairs to compensate for the differnt levels on the first floor. Sixteen of the bedrooms are single and two have en-suite facilities. The one double bedroom exceeds the recommended size. Communal space is good with a choice of two sitting rooms and two dining rooms and toilets and bathrooms are located throughout the care home. The home are committed to delivering care in a manner that meets the needs of each service users and recognises individual choice and preference. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned announced inspection took place on 3 October 2005 over seven hours. Sixteen residents were residing at Harbour House at the time of the inspection. The purpose of the inspection was to consider the work that had been undertaken on the requirements and recommendations set at the last inspection on 3 May 2005 and to inspect other core standards. Therefore some of the key standards that were considered include assessment and care planning, health and safety and staffing arrangements. The registered provider, registered manager, residents and staff were consulted about the services and facilities provided. The environment, records and documents were also considered. Mrs Anson one of Registered Providers home also provided written information about the care home. The requirements and recommendations set at the last inspection had been worked upon and the provider, staff and residents fully cooperated and were very helpful throughout the inspection period. What the service does well:
Each residents has a care plan that is regularly reviewed with them to make sure that all of their needs are being met in a manner that is appropriate and acceptable to the person concerned. Residents stated they were very satisfied with the manner in which their health needs are met. Residents had confidence in the staff diligence about their health and said that health services were accessed promptly and efficiently whenever required. The records indicate that General Practitioners, District Nurses and other health professionals regularly visit the home when required. Residents were also complimentary about the sensitive and reliable support and assistance that staff provide during the periods they are unwell. Residents health needs are also taken account of when any assessment of need occurs and any particular needs an individual has is recorded in their care plan. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 6 Residents said the staff always treated them with dignity and respect and made sure their privacy and dignity was not compromised. The residents stated they found the staff to be attentive, flexible, efficient and responsive to any assistance they require. Many of the residents said they felt in control of their day to day lives and the manner in which there care and support needs were met by the staff. Any concerns or complaints are dealt with positively and the staff and managers are committed to making sure that residents are protected from abuse. A homely, comfortable and well maintained environment is provided and the registered persons continue to consider ways of further improving the facilities available. The decoration, furnishings and fittings are domestic in nature and of a high standard. Residents said they were very satisfied with facilities provided. Two communal lounges and two dinning rooms are located on the ground floor and are popular areas with the residents. Toilets and bathrooms are located throughout the home and within a reasonable distance from the communal spaces. Residents stated they were also very pleased with their bedrooms. Many of the bedrooms are personalised and residents are able to bring their own possessions if they wish. Some of the rooms also have ensuite facilities and it is the providers intention to extend the provision of ensuite facilities over time. The home is clean, hygienic and free of offensive odours. Residents said a good standard of cleanliness was maintained at all times and any issues that arose were dealt with promptly. The staff at the home are an enthusiastic workforce who work well as a team and are mutually supportive. Sufficient numbers staff is employed during waking hours and each night to meet the needs of residents. Additional staff is also employed if this is required to maintain a good standard of care and support. Robust recruitment, selection and vetting arrangements are in place and this makes sure that new staff has the appropriate skills and abilities to provide the care and support required. New staff are also provided with a job description and terms and conditions of employment which sets out their roles and responsibilities. Each staff member is regularly provided with training and this helps to maintain and improve the standard of care and support provided. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 7 The home is well managed and run for the benefit of the residents. Residents are encouraged to comment upon the management arrangements in order to further improve the services and facilities provided. Two residents described their experiences at the home as “a very happy home” and “wonderful staff and food”. What has improved since the last inspection?
Managers at the home complete an assessment of each prospective residents needs to make sure the service is able to provide the care and support required. The information provided in the assessments has improved but in certain instances more detail is required. This will make sure the prospective residents needs, choices and preferences are clear to the staff. In completing an assessment the opinions of the prospective residents relatives or representatives are taken into account as well as any professionals that are involved with the person concerned. Where emergency admissions occur the providers undertake an initial assessment to make sure Harbour House is a suitable setting. A more detailed assessment is then completed during the first week of residency. The views of relatives or representatives and professional are also taken into account. Residents are very satisfied with the care and support provided and stated they were confidant that a good standard of service would continue to be maintained. The residents’ care plans outline the care and support they require to meet their needs, preferences and choices. The staff have improved the information provided in order that the plans comprehensively outline the needs, choices and preferences of each individual. This means that clearer advice, guidance and direction is provided to each member of staff. In certain instances the information provided in the care plans needs to be more detailed to make sure that comprehensive guidance is provided to staff. The staff said they found the plans to helpful and informative in providing care in a manner that reflects the resident’s choice and makes sure their needs are clearly understood. The providers have improved the range of food available each day following consultations with residents. This means that all of the residents’ individual preferences about meals are now taken into account. The records about residents continue to be developed but further improvement is necessary so that all staff are maintaining a comprehensive records.
Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 8 The home provides care to residents who may experience varying levels of physical and mental frailty. In order to maintain independence and safety staff need to identify and respond positively to risks. The arrangements to assess and manage risks needs to continue to be developed to take every reasonable step to provide a safe environment. 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. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 9 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 Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 10 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): 3 Each prospective resident is assessed before moving to the home but some of the assessments would benefit from more detail. This will make sure the prospective resident and the providers are confidant the persons needs, preferences and choices can be met. EVIDENCE: The assessment records of some of the residents that had moved to the care home recently were considered. Where planned admissions occur staff at the home complete an assessment of the prospective residents needs and this summarises the care and support the person requires. This helps the providers to be confident their services and facilities are appropriate to provide the care and support required. In completing an assessment the staff consult with the prospective residents and take account of the opinions of their relatives or representatives and of any professionals that are involved with the person.
Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 11 The information provided could in certain instances be more detailed and also include any preferences and choices the prospective residents many have regarding the care they receive. It is positive that the providers have improved the assessment arrangements following the last inspection of the home. Where residents are admitted on an emergency basis an initial assessment is undertaken to satisfy the registered persons and the person concerned the care home is able to meet the needs identified. A more detailed assessment is then completed during the first week. In these circumstances the prospective resident, their relatives or representatives and any professionals involved with the individual are consulted as far as possible before the person moves to the home and subsequently during the first week of residency. The assessments in respect of residents that are able to direct their own care meet the national minimum standards. Where residents have complex needs or are not able to completely direct their care there are instances where more detailed information needs to be provided in order that staff can have clear information, direction and guidance about the individuals needs, choices and preferences. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 12 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 and 10. The care plans require further improvement in order to provide staff with the information, direction and guidance about meeting all of the persons needs. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Residents are treated with dignity and respect and in a manner that makes sure their privacy is upheld. EVIDENCE: Each resident has a care plan that details the persons care needs and where appropriate any particular preferences or choices they may have about the care and support required. The information provided in care plans has improved and provides staff with a clearer picture of the residents needs. There are some instances where more information is required to make sure that a comprehensive picture guides and directs the staff in the service they provided. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 13 Residents were very positive about the staff group and said they found them to be flexible, responsive and efficient in meeting their needs and any requests they have. The residents stated staff are attentive and respond quickly to any assistances required. The documentary evidence indicates that care plans are regularly reviewed with residents to make sure that needs are being met appropriately and in an acceptable manner. The records of the reviews are very limited and do not indicate the areas considered or if any additional action is required. There are no barriers to residents accessing their care plans at any time. Residents stated they were very pleased and confident about the way their health needs are met. Health services are promptly accessed when required and the records indicate that General Practitioners and District Nurses regularly visit the home when necessary. A District Nurse also visited to see a resident on the day of the inspection. Residents health needs are also taken account of when any assessment of need is undertaken and where required are included in each individuals care plan. Staff that were spoken to were clearly very aware of the importance of diligently monitoring residents health and of taking positive action when any situation arose that caused concern. Residents stated the managers and staff at the home always treated them with dignity and respect. The residents said they felt in control of the care and support provided and were able to determine where they met with visitors and felt fully consulted about their day to day lives. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15 Residents are able to exercise choice and control over their lives. EVIDENCE: Residents said the daily living arrangements were flexible and they were able to direct the care and support provided by the staff. The evidence indicates that residents are regularly consulted about the services and facilities they receive to make sure their rights, preferences and choices are not compromised. There are also no barriers to residents accessing their records when they wish or to residents accessing external advocates when required. The recommendation set at the last inspection for improved consultation with residents about the menu provided was considered. Residents confirmed they had been consulted further about the menu and that the range and choice of food provided each day had been extended. Residents were therefore satisfied with the current arrangements. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 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 Robust arrangements are in place to protect residents against abuse. There are no barriers to residents raising any complaints or concerns with the staff or providers and the evidence indicates that all issues are dealt with in a satisfactory manner. EVIDENCE: Robust policies and procedures are in place to deal with complaints and make sure that residents are protected. Residents and staff comments showed that people are very comfortable about discussing any concerns with the owner or the registered manager. One complaint had been received by the home following the last inspection. The records indicate the matter was dealt with in a suitable manner and to the satisfaction of the resident concerned. No complaints have been received by the CSCI. The staff are clearly aware of the action they are required to take if any complaints are made or any concerns arise about a residents protection. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 16 A suitable policy and procedure is in place to protect residents against abuse, which reflects the Department of Health Guidelines ‘No Secrets. All concerns are reported to the statutory agencies who will coordinate an appropriate investigation. Where necessary the matter is also referred to the police. Arrangements are in place for all staff at the home to complete training about protection issues and the action required if any concerns arise. New staff are also informed of their roles and responsibilities during their induction programme. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 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, 20, 23, 24, 25 and 26. Continued investment provides a homely environment that is maintained to a high standard and is comfortable for those living there and visiting. EVIDENCE: Residents said they were very satisfied with the environment and the facilities provided. The home is a detached property that has been extended over time and is evidently maintained to a good standard. Car parking facilities are provided at the front of the home and an accessible garden for residents is situated at the side of the property. Inside the home there are two communal lounges and two dining rooms on the ground floor. The furniture, fittings and furnishings are of a high standard and domestic in nature. Residents said they found the home to be warm and welcoming and furnished to a good standard. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 18 Bathrooms and toilets are located throughout the home and within a reasonable distance of communal areas. Some of the bedrooms are also provided with ensuite facilities and the registered providers are planning to increase this provision in the future. A number of bedrooms were sampled and found to meet the standards required. Many of the rooms were personalised by the occupant and there are no barriers to residents bringing their own furniture and possessions. The home was found to be clean, hygienic and free of offensive odours. Residents said their rooms were regularly cleaned and they were very happy with the standard attained. The services and equipment provided at the home are regularly maintained and serviced and suitable arrangements are in place to provided a satisfactory level of warmth and heat for residents. The registered providers are considering plans to further extend and improve the facilities. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 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 and 29 Staff morale is high resulting in an enthusiastic and skilled workforce that work positively with residents to provide the care they need and require. EVIDENCE: Staffing levels meet the minimum requirements during waking hours and overnight and additional staff is provided when this is needed to meet the needs of residents. Residents said they were extremely well looked after by the staff that one resident described as “wonderful”. The staff group have a wide range of experience, complementary skills and clearly work well as a team. In addition appropriate training is provided to each staff member to further develop and enhance the services provided. The recommendation set at the last inspection for all new staff to receive a copy of their job description and terms and conditions of employment had been acted upon. This helps staff to be clear about their roles and responsibilities and the standard of care required. Staff were also very positive about working at the home and are clearly committed to providing a high standard of care in a manner that is individually acceptable to the resident concerned. Harbour House DS0000053837.V258533.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 and 38 The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The home is well run and organised for the benefit of the residents. Residents are encouraged to contribute and comment on the manner the home is run on a regular basis. This provides residents with the opportunity to improve the services and facilities provided. Staff are well managed and supported in their duties by the provider and managers which results in an enthusiastic workforce who work positively with residents to provide a positive quality of life. Further attention needs to be given to improving the record keeping arrangements for residents. This will further improve the quality of life provided. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 21 A range of safe working practices has been established to promote the health and welfare of residents and staff. The arrangements to manage and assess risks continue to develop but further improvement is required. This will make sure that every reasonable step is taken to provide a safe setting. EVIDENCE: The home is well run and managed by the registered persons and registered manager. Residents said it was a very “happy home” and they were very confidant about the manner in which the services and facilities are organised and managed. The registered persons and the registered manger have substantial experience of social care and financial management and are suitably qualified. There is also a good history of compliance with the national minimum standards and Care Homes Regulations 2001. To assist in the day to day mange met of the home a deputy manager is in post and senior care assistants have been appointed. The post holders directly assist the registered manager in the delivery and coordination of the daily services and facilities provided. This means that a senior staff member is on duty for all waking hours and a nominated manager is on call each night to assist with any emergencies that occur. In addition one of the providers, Mrs Anson takes an active role in the management and provision of care at the home. The staff said they were well supported and supervised in their work and were positive about the arrangements in place. The staff commented that the managers were approachable and available to offer guidance, assistance and support when this was required. Residents also stated that they were confidant the home is run in their best interests and the providers take account of their views and opinions. The providers continue to establish and develop with service users the arrangements for monitoring quality assurance. Regular meetings are held with residents about the operation of the home and in addition informal individual discussions also occur. The evidence also indicates that other consultations occur with residents and staff but at this time the findings and conclusions are not published. The record keeping arrangements at the home continues to improve. A daily record is maintained for each resident that details the events that have taken place and any concerns that have arisen. The records do not always indicate
Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 22 the action that is required about any concerns or outcome of that action. Improved records will make sure that staff are provided with a clear picture of each situation and any additional action or support they are required to take. The owner does not regularly provide the Commission with a monthly report about the services and facilities provided as required by regulation. Following the last review the frequency that reports are completed has improved. The providers have established a range of policies and procedures to promote safe working practices at the home. In additions staff have received appropriate training to make sure that the health, safety and welfare of residents and the staff themselves is not compromised. The arrangements to manage and assess risks continue to improve. Following the last inspection a format for recording all risk assessments has been established. Risk assessments are completed when situations arise that could compromise the welfare or well being of a resident or staff member. The records indicate there continues to be some situations where an assessment had not been completed when this was required. The improved arrangements result in a clear statement about the risk or concern that has been identified. Where it is viewed that additional action is required to promote health and safety the guidance provided to staff could on occasions be more detailed to make sure that residents and staff’s safety is not potentially compromised. There was however no evidence that a policy and procedure had been established regarding staff managing aggression in the workplace. This should be established to provide staff with appropriate guidelines and standards of care in the event of encountering aggression. This will also further protect residents and staff. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 4 28 x 29 4 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 2 x x x 2 2 Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? none 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 Standard OP3 OP7 Regulation 14 15 Requirement More detailed assessments of need must be completed. All care plans must set out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. The kitchen flooring must be replaced. The annual review of the quality of care provided must be published and valiable to service users. Regulation 26 reports must be received by the Commission each month. Service users records must deatil the events of the day, any concerns and any action taken or required to be taken by staff Risk assessments must be completed when any situation arisese that could potentially compromise the health and safety of service users or staff. Timescale for action 30/01/06 30/03/06 3 4 OP15 OP33 13 24 30/12/05 30/03/06 4 5 OP37 OP37 26 12 and 17 30/12/05 30/01/06 6 OP38 13 30/12/05 Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 25 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 Refer to Standard OP3 OP38 Good Practice Recommendations The person concerned or their relatives or representatives should sign all assessments and care plans. A policy and procedure should be established about aggression in the workplace. Harbour House DS0000053837.V258533.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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