Inspection on 08/04/08 for Hayes Court

This inspection was carried out on 8th April 2008.

CSCI found this care home to be providing an Adequate service.

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

Hayes Court 29/05/07

Hayes Court 29/06/06

Hayes Court 22/02/06

Hayes Court 18/07/05

Hayes Court 14/01/05

Hayes Court 19/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Hayes Court Hayes Court Nursing Home 50 Hayes Lane Kenley Surrey CR8 5LA Lead Inspector Mohammad Peerbux Key Unannounced Inspection 8th April 2008 09:00 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 Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hayes Court Address Hayes Court Nursing Home 50 Hayes Lane Kenley Surrey CR8 5LA 020 8660 3432 020 8668 4522 sturgesshayes@aol.com www.hayescourt.com Dr Michael John Sturgess 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) vacant post Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56) of places Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A variation has been granted to allow one named service user (male) under the age of 65 to be accommodated for respite care. The CSCI must be advised when the service user no longer resides at the home. One (1) place for a service user under the age of 65, requiring general nursing care, can be accommodated. 29th May 2007 Date of last inspection Brief Description of the Service: Hayes Court is a 56-bedded care home. It provides both nursing and residential care. The home is set in its own quite substantial grounds about a mile from Kenley railway station. Access for wheelchair users is available. There are three floors with access by stairs or a small passenger lift. The home provides the possibility a double room on each floor, though only one can be occupied doubly at any one time to keep within the registered number. The remaining bedrooms are all single occupancy; all bedrooms have en-suite facilities. The majority of rooms are located on the ground floor, with a small number in the original main building on first and second floors. There are a number of communal areas located throughout the home, and a conservatory for the use of residents. Parts of the garden are also accessible to them. Visitors may be seen in private in residents rooms, or in one of the small lounges. The range of weekly fees is between £480 and £750. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2008/2009. In writing the report, consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. This is the first key unannounced inspection for the year 2008/2009.This inspection was facilitated by the Acting Manager who has been in post for the past ten months. The Training and Personnel Manager was also involved in the process. Some of the residents were spoken to and they commented positively on the care they are receiving. One resident stated, “The staff look after me well”. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. A tour of the building was also carried out. All registered adult services are now required to fill in an annual quality assurance assessment (AQAA) .It is a self-assessment that the provider (owner) must complete every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. Some information from this AQAA is included in the report. What the service does well: Comments from residents were generally positive, with indication that staff are kind and helpful in meeting their care needs. The home has a settled staff group and has the numbers and skill mix of staff sufficient to meet residents’ needs. Residents were observed to be treated with respect by staff and to have their privacy and dignity respected. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them. The home has a training plan and intends to train its staff in health care to achieve accreditation. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 6 The home is pleasantly designed and furnished, providing communal living, recreational and dining space that meets individual and collective needs. 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. The summary of this inspection report can be made available in other formats on request. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 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 Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home undertakes an assessment of the healthcare needs of residents prior to their admission to ensure that their needs would be met. EVIDENCE: Three residents’ files were sampled at random and evidence suggests that prospective residents have a needs assessment carried out before they are admitted to the home. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Intermediate care for rehabilitation and return to the community is not provided by this home. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally, residents’ care plans include detailed information about their needs and personal goals. This helps staff to know the residents’ needs and how to meet them. However the system for administration/non-administration of medication is poor and potentially place residents at risk. EVIDENCE: A number of care plans were checked and it was noted that there have been a big improvement since the last inspection. It was positively noted that areas on social care needs have now been addressed and the care plans included all aspects of the health, personal and social care needs of the residents. The care plans are being reviewed regularly involving the person and their representatives, as appropriate. Reviews focus on asking what has worked for the individual, where there are progress, achievements, concerns and identifies action points. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 10 The home actively promotes the residents’ right of access to the health and remedial services that they need, both within the home and in the community. Records show that the home arranges for health professionals to visit residents in the home and provides facilities to carry out treatment. The acting manager stated that three of the residents have pressure sores and the staff are monitoring these and the tissue viability nurse is also involved. The provider has bought new mattresses to improve comfort and reduce the risk of pressure sore. The medication administration records (MAR) were audited. It was noted that one resident has been prescribed “Gaviscon” to be administered on a regular basis at nighttime however there were 13 signatures missing on the MAR sheet. While it transpired that there were acceptable explanations for this, these explanations had not been recorded. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. The administration/non-administration of all medication must be recorded accurately at all times to ensure that the residents are having/not having their medication for their health and wellbeing. This will also prevent errors and mishandling of medication. Some items of medication were prescribed, “use as directed”. No other directions were seen for administration. There must be clear direction for all items of medication to ensure that residents are receiving their medication accordingly and as prescribed by the General Practionner.Again this will ensure the health and wellbeing of the residents as far as medication is concerned. There is a record for medication being received in the home however two items were checked randomly and no records were available for them. All medication being received in the home must be recorded accurately to ensure that there is no mishandling. One of the residents administers her inhaler by herself however no risk assessment was available regarding this. All residents who are able to selfadminister medication must have a risk assessment carried out to ensure that they are taking/having their medication as prescribed. During the inspection it was noted that prescribed medications (creams) were left unattended and unlocked in residents’ bedrooms. There was no risk assessment to show that keeping creams in this was is safe and does not present an unnecessary risk to people who live in this home. A risk assessment must be carried out where medications are kept in residents’ bedrooms. Furthermore medicines must be stored so as prevent harm to people living in the home. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 11 It was also noted that some of the times for the administration of medication were being changed and did not matched what was printed by the pharmacist on the MAR sheets. For example one medication was prescribed for 8 am however the time has been changed to 10 am by the home staff. This was discussed with the acting manager who gave assurance that she would ensure these issues are rectified. The Commission would continue to monitor the situation and if there is any further concern this might lead to enforcement action being taken against the home. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms. Residents who were spoken to stated that they are happy with the way that the staff deliver their care and respect their dignity. One resident stated, “The staff look after me well”. Another resident stated, “ The staff are good to me”. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed residents, and they were seen to be polite and friendly. There was evidence of resident’s last wishes in the care plans in as much as relatives had been consulted about whether they wished resuscitation to take place. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are being provided with a range of opportunities for recreational and social activity that is in accord with their social and cultural needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Staff are aware of the need to plan the routines and activities of the home in a way, which meets the choice, and wishes of residents. The home tries to be flexible and attempts to provide a service, which is as individual as possible by using its staff and resources effectively. As far as possible the residents are consulted on how the home can work to provide them with a flexible lifestyle, and to achieve their wishes. The home is looking into improving activities for cognitively impaired residents. The home has open visiting arrangements and residents know they can entertain their family and friends in their own room. If they prefer they can Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 13 use communal areas of the home to talk to visitors. It is clear that the home encourages individuals and groups from the community to visit the home. The home also holds regular meetings with the residents. Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. Residents have the choice to bring personal possessions with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. Staff are ready to offer assistance in eating where necessary, discreetly, sensitively and individually, while independent eating is encouraged for as long as possible. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are generally managed well, which should ensure that residents’ and relatives’ concerns are listened to. There are policies and procedures for safeguarding people who use the service but staff are not always familiar with the guidance, which might put the residents at risk. EVIDENCE: The home has a complaints procedure that is conspicuously displayed in the home for all to view. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint. The home has in place procedures for responding to suspicion or evidence of abuse and passing on concerns to the Commission For Social Care Inspection. The training and personnel manager stated that all staff working within the home are fully trained in Safeguarding Adults and know how to respond in the event of an alert. As part of the inspection process two qualified nurses and one carer were interviewed on their knowledge for reporting alleged abuse. All three staff stated that they would investigate any incident of alleged abuse. One of the qualified staff who is sometimes left in charge of the shift, did not even mention that she would report any alleged abuse to the local Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 15 Safeguarding Team. This is very concerning to the Commission as this would contaminate any investigation that would be carried out by the Care Management Team. All staff especially staff who are shift leaders must have refresher training in the prevention of residents from being harmed or suffering abuse or being placed at risk of harm and/or abuse. Their knowledge and understanding in this area must also be constantly checked at team meetings and during supervision sessions. It is also recommended that other training around dealing with physical and verbal aggression is also made available to staff as needed. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet residents’ individual and collective needs in a comfortable and homely way. Residents’ bedroom are personalised to reflect their individual needs, and personalities where possible. Overall the home was decorated to a good standard throughout and appeared to be comfortable, bright and warm. The home has a rolling maintenance programme in place. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 17 The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. However it was noted that COSHH materials were left unattended by the cleaner when in use as this potentially places residents at risk. There is clear guidance in place in the home informing all staff that COSHH materials must be not left unattended. COSHH materials are kept locked and not left unattended in accordance to Control of Substances Hazardous to Health Regulations (COSHH) 1999. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has the numbers and skill mix of staff sufficient to meet residents’ needs and ensure their safety. There is a staff training and development programme in place. This ensures that staff fulfil the aims of the home and meet the changing needs of residents. EVIDENCE: Resident spoken to during the visit all said they were happy with the care provided, they found the staff friendly and helpful. Generally residents have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. The acting manager informed that more than 50 of staff have an NVQ level qualification at level 2. Recruitment procedures seemed appropriate. Three staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 19 The home ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The training and personnel manager is aware that there are some gaps in the training programme. These are being addressed and further training sessions have been arranged for example training in Dementia care and Parkinsonism. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home generally provides guidance and direction to staff to ensure residents receive consistent quality care. There is a quality monitoring system and this ensures the home is run in a way that is in the best interests of the residents. EVIDENCE: The acting manager has been in post since June 2007, she has the required experience and skills to run the home. She works to continuously improve services and provide an increased quality of life for residents. There has been ongoing discussion with the registered provider to ensure that the acting Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 21 manager register with the Commission to become the registered manager of the home. However there has not been any application received so far and therefore a requirement is made now for the acting manager to apply to the Commission to become the registered manager for Hayes Court. Effective quality assurance and quality monitoring systems, based on seeking the views of residents, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The acting manager informed that the home does not look after any resident’s money. Three staff supervision records were sampled and it was noted that the staff have had only five sessions instead of six. Formal supervision sessions must be held with all care staff at least six times a year for the delivery of good quality services. There was also no evidence the staff are having annual appraisal. All staff must have an annual appraisal with their line manager to review their performance against their job descriptions and agree career developments plans. This will ensure staff fulfil the aims of the home and meet the changing needs of residents. Records with regards to health and safety are of a good standard and are routinely completed. Certificates relating to health and safety were up to date servicing certificates. These included electrical wiring and installation, gas safety, fire safety and lift maintenance. However it was noted during the tour of the home that one of the fire doors were not closing fully. Fire doors must be checked on a regular basis to ensure that they are closing fully for the safety of staff and residents. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 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 N/A 3 X 2 Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No. 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(2) 17(1)(a) Schedule 3 (3)(i) Requirement The administration/nonadministration of all medication must be recorded accurately at all times to ensure that the residents are having/not having their medication for their health and wellbeing. This will also prevent errors and mishandling of medication. Timescale for action 08/05/08 2. OP9 13(2) There must be clear direction for 08/05/08 all items of medication to ensure that residents are receiving their medication accordingly and as prescribed by the General Practionner.Again this will ensure the health and wellbeing of the residents as far as medication is concerned. All medication being received in 08/05/08 the home must be recorded accurately to ensure that there is no mishandling. All residents who are able to self-administer medication must have a risk assessment carried out to ensure that they are DS0000019027.V361394.R02.S.doc 3. OP9 13(2) 4. OP9 13(2) 08/05/08 Hayes Court Version 5.2 Page 24 taking/having their medication as prescribed. 5. OP9 13(2) A risk assessment must be carried out where medications are kept in residents’ bedrooms to show that this was is safe and does not present an unnecessary risk to people who live in this home. Furthermore medicines must be stored so as prevent harm to people living in the home. All staff especially staff who are shift leaders must have refresher training in the prevention of residents from being harmed or suffering abuse or being placed at risk of harm and/or abuse. Their knowledge and understanding in this area must also be constantly checked at team meetings and during supervision sessions. 08/05/08 6. OP18 13(6) 08/06/08 7. OP26 13(4) COSHH materials are kept locked 09/04/08 and not left unattended in accordance to Control of Substances Hazardous to Health Regulations (COSHH) 1999. The acting manager must apply to the Commission to become the registered manager for Hayes Court. Formal supervision sessions must be held with all care staff at least six times a year for the delivery of good quality services. 08/07/08 8. OP31 9 9. OP36 18(2) 08/07/08 10. OP36 18(2) All staff must have an annual 08/07/08 appraisal with their line manager to review their performance against their job descriptions and agree career developments plans. DS0000019027.V361394.R02.S.doc Version 5.2 Page 25 Hayes Court 11. OP38 13(4) Fire doors must be checked on a regular basis to ensure that they are closing fully for the safety of staff and residents. 09/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP18 Good Practice Recommendations It is also recommended that other training around dealing with physical and verbal aggression is also made available to staff as needed. Hayes Court DS0000019027.V361394.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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