Inspection on 26/08/05 for Hazlewell

This inspection was carried out on 26th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Hazlewell 03/03/10

Hazlewell 02/06/09

Hazlewell 18/12/08

Hazlewell 23/06/08

Hazlewell 16/01/08

Hazlewell 16/07/07

Hazlewell 21/04/06

Hazlewell 14/04/05

Hazlewell 01/09/04

Hazlewell 22/04/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hazlewell 29-31 Hazlewell Road Putney London SW15 6LT Lead Inspector Jon Fry Unannounced Inspection 26th August 2005 12:30 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 Hazlewell DS0000019097.V249918.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. Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hazlewell Address 29-31 Hazlewell Road Putney London SW15 6LT 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) 020 8788 8753 020 8780 5736 Mr D Patel Mrs Rosemary Carmen Molloy Care Home 29 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (29) of places Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Dementia The home may provide accomodation and care for one named service user with dementia. The category DE(E) must be removed once this named service user is no longer accomodated. 14/04/05 Date of last inspection Brief Description of the Service: Hazlewell is a twenty nine bedded care home providing nursing care for older people. The property consists of two semi-detached Victorian houses that have been combined to make one home. The home is on three storeys and has been extended to the rear with a large conservatory. There is a sizeable rear garden with a patio area available. The home has twenty three single bedrooms and three double bedrooms. Hazlewell is situated in a quiet residential street reasonably close to available shops and transport links in Putney. Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one afternoon in August 2005 with the visit lasting approximately four hours. The focus of the visit was to check compliance with a number of unmet Requirements as identified at previous inspection visits. A full tour of the premises was undertaken and a number of care records were inspected. Six residents were spoken with individually at the time of inspection. Following this inspection visit, Enforcement Notices were issued with regard to four areas of ongoing concern, namely the poor decorative state of the ground and first floor hallways, the poor condition of carpeting in the first floor hallway, the provision of suitable bathing facilities on the upper floors of the home and the secure storage of potentially hazardous substances. These Notices require the registered persons to comply with the applicable Regulations by early October 2005 or be liable to prosecution without further notice. The registered persons have the right to make written representation within 28 days to the CSCI regarding the Notices served. A further unannounced inspection visit to the home was undertaken by a specialist Pharmacist inspector on the 22nd September 2005. Their findings are included within this report. What the service does well: What has improved since the last inspection? The main lounge has been re-decorated and has had new carpet fitted since the previous inspection visit. Suitable shading has additionally been provided within the conservatory area. Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 6 Issues as identified by the Fire Safety officer and highlighted in the previous report have been fully addressed. 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. Hazlewell DS0000019097.V249918.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 Hazlewell DS0000019097.V249918.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): 3. An adequate assessment process is in place at the home. The home ensures that the needs of prospective residents are assessed prior to admission. EVIDENCE: Prior to any admission to the home staff visit prospective residents and carry out an assessment of individual needs to ensure that on admission staff are aware and are prepared for the resident. Where a resident is placed via the local authority a copy of the care management assessment is made available to the home. This ensures that the home has the relevant information in order to develop a care plan for the individual. Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, 10 and 11. Care plan documentation in place for individual residents requires further review and development to ensure that identified care needs are being fully addressed. Residents are treated with respect by the care staff working at the home. The home has arrangements for the ordering, storage, recording, administration and auditing of medication and has access to a pharmacist for advice. On the day of the visit errors and omissions in recording and an unlocked fridge were found although that may have an effect on the health and welfare of residents. EVIDENCE: Feedback from individual residents regarding the care provided at the home was positive. Comments included ‘the staff are very nice’ and ‘they look after you very well’. Care documentation for two residents was examined in detail. Both care plans had not been fully reviewed since June 2005 and were seen to require Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 10 updating. The inspector identified that one resident had a pressure sore from the nursing notes maintained but there was no corresponding wound assessment or plan of care in evidence. The daily notes for another resident reported that a small sacral sore was noted and treated in August 2005 but the inspector was again unable to examine care documentation regarding this issue. As stated within the previous report, further development work must be undertaken with regard to ensuring that the care documentation reflects the care of the whole person and addresses social and emotional needs. These areas are still not being fully addressed by the home. Risk assessment documentation was observed to be in place for both residents regarding the risk of falls, use of cot sides and moving and handling. These were seen however to require updating – one resident had suffered a fall in early August 2005 but the applicable risk assessment had not been updated since April 2005. An assessment regarding the risk of skin breaks had not been reviewed since May 2005 and documented the resident’s skin as being intact despite the recent nursing notes indicating that the individual had a pressure sore. It is essential that risk assessment documentation be subject to regular review to fully ensure the safety and welfare of residents accommodated. As noted at the previous April 2005 inspection visit, a number of entries were observed within the daily notes during the inspection visit stated ‘care continued’. The inspector supplied the home with further guidelines for the qualified staff regarding their record keeping. It is essential that individual staff familiarise themselves fully with the Nursing & Midwifery Council guidelines regarding record keeping and put this knowledge into practice to fully ensure that the needs of individual residents are being met. The pro-forma in place for the recording of individual arrangements following death were completed for the two residents whose care documentation was examined. The findings of the Pharmacist Inspector following the visit undertaken on the 22nd September 2005 were as follows: All medications administered by staff along with the policies and records relating to receipt, storage, administration and disposal of medication were examined. The nurse in charge and manager were interviewed, the audit records reviewed and the amount of medication counted and compared to the amount that should be in stock for all medication not supplied in a monitored dosage system to ensure residents receive their medication as prescribed. From these observations and discussions policies and procedures were seen covering all aspects of medication management. The policy on disposal of medication being re-written in line with new arrangements. Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 11 One hand-written medication entry on the administration record was not written fully in words. Two residents had missing entries on the administration record indicating administration/non-administration of medication. Two residents did not have the administration of medication recorded as prescribed by the doctor. In all these instances it was determined the correct medication had been given. Three residents did not have the amount of medication given recorded for items prescribed with a variable dose making it difficult to assess whether the medication had been given correctly. The amount of medication in stock agreed with the amount that should be in stock for all other medications indicating that residents had been administered their medication as directed unless otherwise recorded. The fridge was not lockable. The office is normally left open and residents would have access to any medication in the fridge. The manager stated that the administration records are audited monthly. No records were seen. An audit of all medication and records is done six monthly. A record of the last audit was seen. Registered nurses administer medication to all residents. All other records had been completed accurately and provided evidence that all medication had been administered correctly, changes to medication clearly identified, al other medication was stored and administered safely by appropriately trained staff. All these ensure that the health and welfare of service users are protected Hazlewell DS0000019097.V249918.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 and 13. In–house activities are provided on an informal basis. There is scope for this provision to be developed and improved upon. Residents are able to maintain contact with family and friends as they wish. EVIDENCE: Daily records of activities provided were examined. The deputy manager reported that there was still no structured programme of activities in place but one qualified member of staff took the lead in ensuring their provision informally. Recent activities documented were seen to include watching TV, listening to music, music & movement, doing nails and chatting. Trips out into the community for social and recreational purposes as provided by the home were not evidenced within the maintained record. Comments from residents included ‘I am quite content‘ and ‘I would like to go out to Wimbledon Common’. Staff present reported that residents were able to utilise the garden area of the home and a gazebo was seen to have been erected for shading. The inspector noted that the garden required some attention as it presented as slightly overgrown at the time of this inspection. Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 13 Requirements have again been made for the home to ensure that sufficient social and recreational opportunities available to residents. It is also essential that opportunities be provided to residents who choose to engage in activities taking place outside of the home. Two residents were observed to have visitors at the time of this inspection. Another resident reported that they were able to have visitors ‘at any time’. Hazlewell DS0000019097.V249918.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 and 18. The home must ensure that any complaints made are fully investigated and acted upon. It is essential that the investigation of complaints is used as a learning exercise for the home and the information gained is used to further improve the service. Assessments in place for the use of cot side equipment require updating to ensure the welfare of individual residents. Equipment in use for this purpose must be in full working order. EVIDENCE: The CSCI has received two complaints directly regarding the service since the previous inspection took place. One of these complaints was investigated by the CSCI following dissatisfaction from the complainant with the response from the home following an internal investigation. The issues raised were found to be upheld or part upheld by the CSCI due to identified shortfalls within the service provision. These issues concerned poor communication by the home with the relatives of a resident and improvements required to the care planning practices within the home. A further complaint was received in August 2005 regarding the beds provided at the home. This has been referred to the provider for investigation using the home’s own complaints procedure. It is essential that residents, their representatives and other stakeholders in the service have confidence that any issues raised will be looked at seriously Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 15 and acted upon if necessary in an open and transparent manner. Complaints regarding any service should be used as a learning exercise and to develop best practice as appropriate. The CSCI has received two letters of compliment regarding the service since the previous inspection took place. One comment made spoke of the ‘tender loving care’ shown by the staff at the home. Cot side equipment was observed to be in use in two instances during this inspection visit. The assessments examined for their use within the care plans both stated that protectors were in use with the equipment. This was not the case at the time of inspection – the deputy manager stated that the resident routinely removed these but this was not indicated on the assessment seen. As stated previously within this report, risk assessments must be subject to review to ensure they fully address potential safety and welfare issues for individual residents. The cot side in use for the other resident was seen to be secured with a bandage at one end and had no protector in place. An Immediate Requirement was made immediately following the inspection visit and is included within this report. Hazlewell DS0000019097.V249918.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, 22, 24, 25 and 26. There has been one significant change to the décor since the previous inspection visit. Further redecoration work must take place to create a pleasing and pleasant environment for service users. The continued lack of investment reflects poorly on the home and the registered provider. The current provision of suitably adapted bathrooms remains inadequate to meet the needs of residents. A number of individual bedrooms provide homely and comfortable accommodation for residents. This standard is not consistently maintained throughout the home and a number of shortfalls were identified. EVIDENCE: The lounge area of the home has been redecorated since the previous inspection with new carpet also having been fitted. Suitable shading was Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 17 additionally noted to have been provided within the conservatory area of the home. As stated within the previous inspection report there is tremendous potential for this service to provide comfortable and homely accommodation for residents that is of a very high quality. The appearance of the lounge has improved immeasurably and this standard must now be applied throughout the premises. The inspector was however again disappointed to note that a number of Requirements made at the previous inspection concerning the physical environment remain outstanding. The lack of suitable adapted or accessible bathing facilities on the upper floors of the home continues to be of concern. The deputy manager reported that the first floor adapted bath and ground floor shower were the facilities in use at the time of this inspection. It was again noted that this was the situation at the time of the previous inspection. As stated within the summary of this report, Enforcement action was taken by the CSCI immediately following this inspection. This was taken with regard to the poor decorative state of the ground and first floor hallways, the poor condition of carpeting in the first floor hallway and the provision of suitable bathing facilities on the upper floors of the home. An Immediate Requirement was additionally made concerning the beds provided for three residents at the time of inspection. This equipment was seen to be either old or in poor condition. Further consideration must be given to the standard of decoration and furniture provided within individual bedrooms. A number of bedrooms present very well and are personalised to the individual but this standard is not consistently maintained throughout. The inspector noted that the ceiling in one bedroom had been re-decorated as required. A chest of drawers in one bedroom was seen to be in very poor condition and the ceiling in another room still required redecoration. The deputy manager reported that an electric hoist had now been provided at the home and that this equipment had been financed via a relative’s donation. Hazlewell DS0000019097.V249918.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. Staffing levels remain adequate to meet the care needs of residents currently accommodated. Further consideration must be given to ensuring that individual social and recreational needs are being fully addressed. EVIDENCE: Comments from residents regarding staff included ‘the staff are very good’, ‘nice’ and ‘friendly’. One resident spoke very highly of two members of staff in particular and how they took time to converse with them regularly. Staffing levels were observed to be adequate to meet the care needs of residents accommodated. As stated within the section regarding daily life and social activities, further development work must be undertaken to enhance the social and recreational opportunities available to residents. Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 19 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): 38. Procedures regarding the storage of potentially hazardous substances require further review to fully ensure the safety of residents. EVIDENCE: Three instances were observed where potentially hazardous substances were not stored securely at the time of inspection. This potentially compromises resident safety and this issue has been a made a Requirement at the two previous inspection visits of the home. An Enforcement Notice was issued following this inspection visit. The inspector noted that four wheelchairs stored in a hallway of the home had no footplates fitted at the time of inspection. Accident records were seen to be maintained. The inspector noted that the accident book examined made record of a number of falls that had not been Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 20 notified as required to the CSCI. This was the situation at the time of the previous inspection visit. The registered manager must ensure that all incidents adversely affecting the welfare of residents are notified to the CSCI. It was additionally noted that tippex had been used to amend the record on two occasions – this is not good practice within records such as these. Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 21 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 2 8 X 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 2 2 X 2 2 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP 7 Regulation 12 (1) 15 Individual care plans fully address health, personal and social care needs of residents. Daily care notes must be completed in line with NMC guidelines. (Previous timescale of 01/06/05 not fully met) 2 OP 7 12(1)b 15(2) 17(1)a The Registered Persons must ensure that: All care plans must be reviewed on a monthly basis with full records kept. Full and detailed assessment documentation is put in place for all wounds / pressure sores as required for individual residents. (Immediate Requirements issued 30/08/05) 09/09/05 Requirement The Registered Persons must ensure that: Timescale for action 01/11/05 Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 23 3 OP 9 13 (2) The Registered Persons must 02/09/05 ensure that all items of medication (including creams) be securely stored at all times. (Immediate Requirement issued 30/08/05) 4 OP 9 13 (2) The Registered Persons must ensure that the administration of all medication is recorded accurately. 10/10/05 5 OP 9 13 (2) The Registered Persons must 10/10/05 ensure that the medication fridge is lockable. The Registered Persons must ensure that there is a full programme of activities in place at the home. A dedicated trained member of staff must be provided in order to effectively deliver this programme. The programme provided must enable residents to engage in local, social and community activities. (Previous timescale of 01/07/05 not fully met) 01/11/05 6 OP 12 16 (2) (m) (n) 7 OP 16 22 8 OP 7 OP 18 12 (1) 13 (4) 9 OP 18 13 (4) 23 (2) (c) The Registered Persons must ensure that all complaints made are fully investigated and acted upon. The Registered Persons must ensure that assessments in place for the use cot side equipment are kept under review and updated as necessary. The Registered Persons must ensure that all cot side equipment is fully functional with DS0000019097.V249918.R01.S.doc 01/10/05 01/10/05 09/09/05 Hazlewell Version 5.0 Page 24 protectors in place as required. (Immediate Requirement issued 30/08/05) 10 OP 19 23 (2) (b) (c) (d) The Registered Persons must ensure that the ceiling in room 19 is re-decorated. The Registered Persons must ensure that the garage is kept locked at all times. (Previous timescale of 01/05/05 not met) 12 OP 22 23 (2) (c) The Registered Persons must ensure that the beds located in bedrooms 9, 12 and 17 are replaced. The Registered Persons must provide written evidence to the CSCI that the stair lift has been serviced. The Registered Persons must ensure that the chest of drawers located in room 12 is repaired or replaced. The Registered Persons must ensure that the sluice room is refurbished. This area must be kept in a clean and hygenic state at all times. (Previous timescale of 01/07/05 not met) 16 OP 29 7, 9, 19 The Registered Persons must ensure that Criminal Records Bureau (CRB) disclosures are obtained for any persons working at the home on a regular basis. This is with particular reference to the domestic staff member / maintenance person. Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 25 01/11/05 11 OP 20 23 (2) (o) 01/09/05 03/10/05 13 OP 22 23 (2) (c) 01/11/05 14 OP 24 23 (2) (c) 01/10/05 15 OP 26 23 (2) (d) 01/11/05 01/11/05 (Requirement not fully assessed during this inspection visit – carried forward with new timescale) 17 OP 30 18 (1) The Registered Persons must ensure that the individual records of training are fully compiled and kept up to date. (Requirement not fully assessed during this inspection visit – carried forward with new timescale) 18 OP 30 18 (1) The Registered Persons must ensure that all new staff receive induction training to sector skills specification within six weeks of employment. Full records must be maintained to evidence this. (Requirement not fully assessed during this inspection visit – carried forward with new timescale) 19 33 24 The Registered Persons must 01/11/05 ensure that an annual development plan be put in place for the home. This must reflect the views of residents, their representatives and other stakeholders in the service. (Requirement not fully assessed during this inspection visit – carried forward with new timescale) 20 36 18 (2) The Registered Persons must ensure that all care staff receive 1-1 supervision at least six times DS0000019097.V249918.R01.S.doc 01/11/05 01/11/05 01/11/05 Hazlewell Version 5.0 Page 26 annually. (Pro-rata for part-time staff). Persons giving supervision must be appropriately trained to do so. (Requirement not fully assessed during this inspection visit – carried forward with new timescale) 21 OP 38 13 (4) The Registered Persons must ensure that footplates are used on wheelchairs at all times. (Previous timescale of 01/05/05 not fully met) 22 OP 38 37 The Registered Persons must ensure that the CSCI is notified of all events adversely affecting the well-being of residents. (Previous timescale of 01/05/05 not fully met) 01/09/05 01/10/05 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 OP 9 OP 9 OP 16 Good Practice Recommendations It is recommended that the dose of medication on handwritten entries be written fully in words. It is recommended that a written record be made of the manager’s monthly audits. The registered persons should ensure that investigations of any complaints made to the home are utilised as a learning exercise. Hazlewell DS0000019097.V249918.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. 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