Inspection on 16/01/06 for Highdell Nursing Home

This inspection was carried out on 16th January 2006.

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

Highdell Nursing Home 26/02/07

Highdell Nursing Home 16/05/06

Highdell Nursing Home 13/07/05

Highdell Nursing Home 26/01/05

Highdell Nursing Home 06/07/04

Highdell Nursing Home 07/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Highdell Nursing Home 43 Westfield Lane Idle Bradford West Yorkshire BD10 8PY Lead Inspector Valerie Francis Unannounced Inspection 16 January 2006 09:30 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 Highdell Nursing Home DS0000019894.V271171.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. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Highdell Nursing Home Address 43 Westfield Lane Idle Bradford West Yorkshire BD10 8PY 01274 610442 01274 610442 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) Mr Stephen Richard Pelkowski Mr Neville Rowe, Mr R Bottomley, Mrs Anna Margaret Johnson Mr Stephen Richard Pelkowski Care Home 25 Category(ies) of Dementia (25), Mental disorder, excluding registration, with number learning disability or dementia (25) of places Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2005 Brief Description of the Service: Highdell Nursing Home is situated in the village of Idle, Bradford and provides accommodation for up to 25 people with psychiatric problems. Qualified psychiatric nurses and care staff provide twenty-four hour care. Accommodation at the home is provided on two levels with a recently installed lift offering access to the upper floor. This is in addition to the provision of a stair lift. There are single and double bedrooms, some with en-suite facilities. The home has two lounge areas plus a separate dining room. Parking is available to the front of the home and there are gardens to the rear and side. Although the home is situated in a quiet area the bus routes to Bradford and Shipley are easily accessible. Shops and local amenities are within walking distance. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, regulated care homes have a minimum of two inspections a year. These may be announced or unannounced visits. This is the second inspection carried out within the inspection year both inspections have unannounced. There has been one other inspection visit to the home following a complaint that was made. The last inspection took place on the 13th July 2005. This inspection started at 9.30am and finished at 5.30pm. The term residents is used for the people living at the home, this is the term that will be used throughout this report. A pre inspection questionnaire was left at the home but not returned to the office at the time of this inspection report been written. During the inspection records were examined, all areas of the premises were seen, such as communal sitting room/dining room, residents bedrooms, bathrooms, toilets and laundry area. Staff were observed carrying out their work and interacting with residents. Approximately 20 residents were spoken to, either in a group or individually. Two relatives visiting at the time were also spoken to about the care and attention given to their relative living in the home The manager facilitated in the inspection process with some input from the care manager (matron). What the service does well: What has improved since the last inspection? What they could do better: Although some changes had taken place and some of the requirements and recommendations made at the last inspection had been addressed, there was still several that still need to be resolved to make sure that residents live in a home that does not compromise their health, safety and wellbeing and all their care needs met. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 6 The new build to the home has been completed for some time, however there were matters still out standing i.e. certificate from the building control has not been issued, and the fire safety certificate from the West Yorkshire fire service had not been issued, the manager said these are to be obtained. The rooms of this extension are in use, therefore these documents must be sent to the CSCI area office within the given timescale. The registered provider must make sure that the home’s statement of purpose is available in the home and the service user guide is accessible to residents. The registered person must make sure that care plans are reviewed regularly and any changes are reflected in a new plan of care. Residents must have a care plan that clearly identifies all their assessed needs and how they would be met. Residents and or their representative must be consulted in the care planning process. There must be a plan of action to prevent pressure sores occurring and risk assessments in place. The registered person must make sure that all residents have a Nutritional screening assessment. All effort must be made for social activities to be carried out for residents to meet their individual needs. All matters relating to health and safety must be resolved. The mattress on the floor must be removed, the electrical ventilation must be cleaned, and the hot water temperature in the outlet identified to the manager must be resolved and monitored and regular checks made. A record of the water temperatures must be in place. The electrical PAT testing must be carried out with records kept. Window restrictor locks must be put on the windows identified to the manager. The standard of cleanliness of furniture used by residents in communal sitting rooms must continue to improve. Staff must have training on mental health to meet the needs of the people living in the home. 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. Highdell Nursing Home DS0000019894.V271171.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 Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 &5. Resident’s terms and conditions did not have up to date information. No training for specialist care had been arranged for staff. There is an opportunity to visit the home before making a decision to live there. EVIDENCE: At the time of the inspection a copy of the home’s statement of purpose and service user guide was not available for inspection. All but two residents have been given a contract of terms and conditions, during the inspection of the documentation in three files it was evident that there had been no updated information on the changes of fees paid by or on behalf the residents. Not all staff have had training on Dementia, which would enable them to meet the needs of most of the people living in the home. None of the care staff have undertaken courses on other mental health illness, which would enable them in their delivery of care to service users. Prospective residents and their representativeas have the opportunity to visit the home before making up their mind about the home. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 9 The manager must carry out an assessment of care needs to make sure the home can meet the individual needs. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10. Whilst there were care plans in place they did not reflect all the residents needs. No risks identified or assessed was supported with a plan of action for minimising the risk. EVIDENCE: Although there was good assessment information in the three residents care file seen a supporting comprehensive care plan was not in place. The inspector felt that residents would benefit from a care plan approach that was person centred, putting the person first and not the dementia or illness, recognising the needs and emotions of the residents are important. All information should identify all needs with a plan of action for staff to follow. Several risks were identified in the care assessment information but risk assessments were not carried out i.e. residents who were at risk of developing a pressure sore or falling. There were no review notes of any reviews taken place for the resident’s whose care file was seen. There was no written information that indicated that residents and their relatives are involved in the care planning process. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 11 Residents medication is administered by the nurses in charge of the shift, although the home has policies and procedures for safe handling of medicines and self medication, there are no risk assessments carried out for those who self medicate. There was an issue with disposal of medications, the home has medication that should have been disposed of some time ago after the resident had moved from the home or died but as yet a system was not in place to dispose of unwanted medication. The manager, Deputy and one of the night nurses have had training on Palliative care. Staff do not have access to a policy procedure on dying and death. None of the current staff team has had any training on dying and death. It was noted that the home cares for residents who are very frail, yet there was no indication on care files that last wishes were discussed with residents. Highdell Nursing Home DS0000019894.V271171.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): 12,14 &15. Social activities for service users are limited and provide little variety, which is providing the opportunity for boredom and no interest. EVIDENCE: Although there is an activity plan displayed in the home, and some resident’s had taken themselves out, or were out with family, and some were talking to each other, there were certain residents who were walking around the home, with no real staff interaction with them, other that finding them a safe place to sit. They were not engaged in any social stimulation or recreational activities, and many appeared to be bored. No staff had received training on dementia, therefore found it difficult to engage some residents who were at the later stage of their dementia in social activities using the remaining ability to be engaged in activities. There was also no evidence on files of any life history of residents, which may enable staff to use this, to engage residents in an activity that they knew. Residents whose finances are handled by the manager ranges from collecting monies from the post office on behalf of residents, to being appointee for three residents. Relatives or social services handle others. There is a financial policy procedure in place for dealing with resident’s monies. There were no records available in the home of transaction for monies kept on behalf of residents who the manager was appointee for. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 13 Meals are prepared from a three week rotation menu plan, menus are changed seasonally and any specialist diets are catered for. Food served appeared to be appropriate for the resident group, further choice is available for individual. During the inspection of care files it was noted that no nutritional risk assessments have been carried out for any of the residents. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17. There are systems in place to protect the rights of service users. EVIDENCE: The complaints procedure is accessible to residents and their representatives. The manager was advised to find a more prominent place for the policy to be displayed so that both residents and their visitors could see the complaint procedure. Records are kept of all complaints received at the home and from the CSCI area office. One complaint has been received about this service in the last twelve months. A log is kept of all complaints received in the home and from the CSCI office. Where there are no relatives to advocate on behalf of a resident, an advocate is found using an advocacy agency, to make sure that the residents’ rights are respected at all times. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 15 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, 23, 24, 25 & 26. Limited work has been carried out to the building since the last inspection. Not all area of the environment offers a safe place for residents. EVIDENCE: The home is registered for 25 residents, although there are three shared rooms, only one is used as such for this purpose and all others are used as single rooms at the present time. Since the last inspection redecoration of the communal areas and some bedrooms has been carried out. The manager said he was waiting the fitment of a new bath to one of the bathrooms that had recently been redecorated. The home had employed a member of staff to keep the building clean and to make sure that service users rooms and furniture were kept clean to a good standard, however despite the improvement some rooms needed cleaning and easy chairs still had evidence of food debris. A programme of redecoration and replacement of furnishing for the building is needed and a copy of this action asked to be sent to the CSCI area office. During the course of the inspection of the premises several health and safety hazards were noted, these are listed in standard 38. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 16 All communal sitting rooms furniture were showing signs of wear and tear and needed replacing. Some of the bedrooms had ensuite facilities; others had WC’s in easy access of bedrooms without ensuite. The home has four bathrooms, two of which had assisted baths that provide staff with a hoist for lifting residents into the bath. There were other aids and equipment available to assist staff in the process of moving and handling, grab rails are placed in corridors and other areas around the home that is accessible to residents, doorways appeared to be wide enough to accommodate people in wheelchairs. During the inspection of bedrooms it was noted that many bedrooms had an extra mattress on the floor, the manager said this was due to storage space or residents had just been given a new bed. It is acknowledged that some residents had brought their own furniture to the home, which meant that there were varying degrees of personalised rooms. The heating through out the home appeared to be satisfactory for the time of year. However some hot water outlets available to residents was found to be subjectively hot. The laundry system for washing clothing was working well, all staff but one has undertaken an infection control course. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 17 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, 29 & 30. There are not enough staff to meet the needs of residents taking into account the size and layout of the building. It was not possible to check if the home protects and support residents when recruiting staff. Some training is given to staff, but specific training for residents needs i.e. mental health illness was needed. EVIDENCE: Although during the day the numbers of staff caring for residents appeared satisfactory, at night there are only two waking night staff, one trained nurse and a care assistant. This number of staff would seem to be inappropriate for the number of service users, their care needs and the lay out of the building. The manager was advised that some consideration, must be given to improve the staffing levels at night so that both residents and staff health and wellbeing is not compromised. It was difficult to make a judgement if the residents are supported and protected by the home’s recruitment polices and practices as there were no files available in the home. There was also no recruitment and selection policy procedure available for inspection. There was no training plan in place to show that there was a programme with the intended dates for staff training that would support them in their service delivery to residents. All staff was said to have induction training, not all staff have had Dementia training, and the manager said the senior care staff have had training on Dementia and Challenging Behaviour. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 18 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, 32, 33, 34, 35, 37 & 38. The home management team has the qualification to meet the needs of the registered category of the residents. Not all the required records and information was availabe in the home for inspection It was difficult to judge if the home had a recruitment and selection procedure and that the systems protect residents. The lack of a financial recording system could cause the finances of residents not to be safeguarded. The health, safety and welfare of residents are compromised. EVIDENCE: The manager is qualified 1st level Registered mental health nurse, with years of experience of working with the resident group. Plans are in place for the manager to undertake the Registered Managers Award, which is overdue and should be completed within the next six months. During discussion with residents and their visitors they indicated that the manager was approachable. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 19 Annual questionnaires, which are in line with the home’s quality assurance system, are sent to residents relatives about the service provided at Highdell. Questionnaires are also given to residents who had capacity for their feedback on the care and attention given at the home, there was, however no action plan of the outcome has been circulated or made available to all participant or the CSCI. Some of the records that are required to be kept in the home for inspection were not available for inspection. However records that were available were kept in a locked area. Staff have some health and safety training ie, moving and handling and basic food hygiene, no staff have had first aide training and infection control. During the audit of the health and safety records it was noted that there were no records work for Portable Appliance Testing (PAT) testing. There were no records for water checks carried out for legionella, the manager said regular checks are carried out by the home of the water temperatures to ensure the water temperature is stored at 60’c. Several windows needed restrictors to eliminate the risk of someone falling out of the window. The hot water in wc’s were subjectively hot, the electrical ventilation in the bedroom identified to the manager needed cleaning so that fire safety is not compromised. Several of bedroom doors were not closing properly. The carpet on the hallway and in the WC on the top floor was sticky. It was acknowledged that systems have been put in place to ensure this area was clean however, the cleaning process has not worked and the manager said plans are in place to replace the floor covering. The excess mattress in resident’s rooms must be removed to ensure they do not become a trip hazard. Although the inspector was told that residents were only given a key if they had capacity to maintain, there was no evidence on any care file to indicate that risk assessments had been carried out and a written reason given why they do not have a key. No risk assessment for potential hazards around the building and for staff carrying their work was in place. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 20 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 1 2 X 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 1 2 3 3 3 3 1 2 STAFFING Standard No Score 27 2 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 2 X 2 1 Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 21 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 OP1 Regulation 4 Requirement The regisrted provider must make sure that the home’s statement of purpose is available in the home and the service user guide is accessible to residents. The registered person must make sure that care plans are reviewed regularly and any changes is reflected in a new plan of care. Residents and or their representative must be consulted in the care planning process. Residents must have a care plan that clearly identifies all their assessed needs and how they would be met. Last timescale 30th August 2005. There must be a plan of action to be taken to prevent pressure sores occurring and risk assessment in place. Last timescale 30th August 2005. A plan of care with an action plan must be in place, in regards to the use of bed safety rails. Last timescale 30th August. Timescale for action 22/03/06 2 OP7 15 (1) (b) 22/03/06 3 OP7 15 (1) (c) 22/03/06 4. OP7 15 10/03/06 5. OP7 15 & 13 (4) (b) 15/03/06 6. OP7 15 & 13 (4) 15/03/06 Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 22 7 OP8 14 &16(2) (i) 13 (2) 8 OP9 9 OP12 16(n) 10 OP38 23 (1)(c) (4) 11 OP25 23 12 OP26 23 13 OP24 23 14. 15 OP28 OP31 28 9 The registered person must make sure that all residents have a Nutritional screening assessment. The registered person must take action in accordance with the Royal Pharmaceutical Guideline for the disposal of unwanted medicine. All effort must be made for social activities to be carried out for residents to meet their individual needs. All matter relating to health and safety must be resolved. The mattress on the floor must be removed, the electrical ventilation must be cleaned, and the hot water temperature in outlet identified to the manager must be resolved and monitored and regular checks made. A record of the water temperature must be in place. The electrical PAT testing must be carried out with records kept. Restrictor locks must be put on the windows identified to the manager. The water temperature checks must be carried out on a monthly basis and records kept of these checks. Last timescale 30th August 2005. The standard of cleanliness of furniture used by residents in communal sitting rooms must continue to improve. A plan with timescale for replacement and redecoration in the home must be sent to the CSCI area office. Last timescale 30th August 2005. The home must have 50 of staff with an NVQ qualification by March 2006. 31/12/05 The registered manager must have a relevant management DS0000019894.V271171.R01.S.doc 22/03/06 22/03/06 15/03/06 15/03/06 16/03/06 15/03/06 26/03/06 31/10/06 17/05/06 Page 23 Highdell Nursing Home Version 5.0 16 OP30 18 17 OP33 21 (2) 18. OP38 23 qualification Staff must have training on 12/04/06 mental health illnesses to meet the needs of the people living in the home. The regisrted person must make 02/04/06 sure that a copy of the outcome of the quality assurance review is available to residents their representatives and a copy sent to the CSCI. Risk assessments for the building 22/03/06 must be carried out. Last timescale 30th September 2005. The registered person must make sure the new building meet the requirement of the building control and the fire safety authority and a certificate to confirm this must be sent to the CSCI office by the given timescale. 06/03/06 19 OP38 23 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 OP7 *RCN *RCN Good Practice Recommendations Resident/ relatives should sign an agreement to indicate Their consent for bed safety rail in place. Some consideration should be given for the manager to provide a care plan that is person centred. The manager should provide the CSCI with a plan of the redecoration and replacement through out the home. Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Highdell Nursing Home DS0000019894.V271171.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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