Inspection on 05/06/07 for Highfield

This inspection was carried out on 5th June 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Highfield 12/01/10

Highfield 23/09/05

Highfield 10/05/05

Highfield 07/03/05

Highfield 10/09/04

Highfield 12/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Highfield Avon Drive Bedford Bedfordshire MK41 1HB Lead Inspector Leonorah Milton Unannounced Inspection 5th June 2007 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 Highfield DS0000014912.V334824.R01.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. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highfield Address Avon Drive Bedford Bedfordshire MK41 1HB 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) 01234 267196 01234 353046 BUPA Care Homes (Bedfordshire) Ltd Ms J Ballinger Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (34), of places Physical disability over 65 years of age (34) Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd September 2005 Brief Description of the Service: Highfield is a purpose built residential home operated by BUPA Care Homes (Bedfordshire) Ltd. Ms J Ballinger had managed the home for 2.5 years. The home is registered to provide for thirty-four older people who may also have dementia and/or physical disabilities. The accommodation consists of thirty-four single bedrooms over two floors with access via staircases and a passenger lift. Two communal lounges, a reminiscence/ relaxation quiet area and large dining room are located on the ground floor. Another lounge designated for use as a smoking area is also located on the ground floor. A smaller room for use as a family room and private meetings is located on the upper floor. Bathrooms and toilets are distributed throughout the building for convenient access. A well maintained courtyard garden proves an attractive view from much of the building and a pleasant place for relaxation. The home is located in Brickhill, a residential suburb of Bedford with a small shopping centre nearby and Bedford towns amenities accessible via a local bus route. The home has surrounding grounds. Ample parking is available to the side of the home. Weekly fees for accommodation were between £435.86 and £550. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report sets out the significant evidence that has been collated by the Commission for Social Care (CSCI) since the last visit to and public report on, the home’s service provision in September 2005. Reports from the home, other statutory agencies, and information gathered at the site visit to the home, which was carried out on 5th June 2007 between 11.00 and 19.00, were taken into account. The visit to the home included a review of the case files for three people living in the home, conversations with eight people, a visitor, four members of staff and the manager. Much of the time was spent with people in communal areas of the home, where the daily lifestyle was observed. A partial tour of the building was carried out and other records were reviewed. The Commission had received seventeen responses from people living in the home to a questionnaire circulated prior to this inspection. These have been taken into account and reflected in this report. What the service does well: People had received skilled care in comfortable surroundings that were suitable to their needs. The majority of the staff had worked in the home for a considerable time and were well versed with peoples’’ needs and the home’s daily routines. The example set by the manager and her senior team had provided the team with an excellent role model for the care of vulnerable people. The home was well managed. People living in the home had been provided with opportunities to voice their opinions about the service; despite some lapses in the provision of individual supervision, personnel had been well supported through group meetings. People living in the home and a visitor passed much praise about the service and the conduct of the team. The provision of activities in house for recreation and stimulation was good. Activities had taken account of peoples’ abilities, preferences and needs. The range of activities had catered for those with short- term memory loss, as well as the more able. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Records must be maintained in the home to show that recruitment of personnel had included the obtaining of disclosures from the Criminal Records Bureau. People living in the home should be provided with opportunities to take recreational trips out of the home. The room used by those who smoke would benefit from redecoration of the ceiling, replacement of the carpet and the installation of an extractor fan. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 7 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. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 8 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 Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 9 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): Standards 1,2,3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had obtained information about people’s needs before admission to ensure the home had the capacity to properly care for them. EVIDENCE: A copy of the Statement of Purpose was given to the inspector. It provided an easy read guide to the service. The details however were not entirely accurate as a central administrative office was listed as the registered address, which was not the case. Contracts seen showed that terms and conditions of accommodation were clearly set out and detailed were relevant additional charges such as escort for healthcare and similar appointments. Both parties had signed contracts. Three cases files were assessed at this inspection. Each showed that detailed pre-assessments of need had been carried out before people had been admitted. These had included information from placing authorities, and health Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 10 care providers where people had been admitted from hospital. The home had an established admissions procedure that included its own written assessment of need that was also used unless people were admitted under an emergency situation. In most instances, people moving into the home had been reliant on their relatives to visit and assess the home on their behalf. Some however had experienced previous respite stays in the home and indicated that the positive experience of care at Highfield had influenced their decision to move into the home permanently. One person reported, “If you are lucky enough to come to Highfield you are indeed fortunate”. The home provided a respite care service but not an intermediate care service. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 11 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): Standard 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home were predominantly satisfied with the ways in which their care needs had been met. EVIDENCE: Three case files were assessed. The care plans seen were based on detailed assessments of need. Plans covered people’s personal, physical, health, recreational, social and emotional needs. Documents listing peoples’ preferences for their daily lifestyle had been completed. These listed preferred times for getting up and going to bed, preferred meals, beverages, frequency for bathing, hairdressing and similar. Observation of the daily lifestyle and conversations with staff showed that personnel were familiar with people’s needs and how these were to be met. People who contributed to the inspection in writing and when spoken to at the visit were positive about the conduct of staff, describing them as “Kind”, “Very understanding” and “Friendly”. One who came for respite stays stated, “ I am always happy at Highfield. I have no complaints”. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 12 The standard of the care received were described as “Very good” and “Excellent”. Others comments showed that a small percentage of people were not satisfied with the level of support they received, “As always staff are often too busy to respond to requests for the toilet etc as quickly as they are needed”, “Some residents call a member of staff and the staff members more times than not say “I’II do it in a minute.” It can be 2 hours or more or they totally forget altogether”. Others responded that staff were willing to listen and act, “”Unless they are too busy and short staffed”, “When they have the time to do so”. There was evidence to show that service users had been supported to access health care appointments for routine treatments such as chiropody, optical tests and had been referred to their doctors and other specialists as need be. Notifications to the Commission showed that several people had been infected with an infectious disease on two occasions this year. Records indicated that the home had liaised with doctors and the Public Health Department to eradicate these outbreaks. The manager reported that there had been noreoccurrence of the infection for several weeks prior to this visit. Medicines were stored in a purpose built, lockable trolley that was stored in a lockable office when not in use around the home. Spare medicines were stored in locked cupboards within that office. Medicines were only administered by members of the team who had received training in safe practice. A member of staff who had undertaken such training was observed as they administered medicines. During this they were able to explain their understanding of safe practice and were seen to be diligent in this practice. Records inspected showed that medicines had been administered as prescribed. It was noted that prescriptions had been reviewed on a regular basis to ensure that medicines were appropriate to current conditions. Although written guidance for the use of medicine prescribed for use on an “as and when” required basis was not in place for each individual it was evident that staff had an awareness of the appropriate use of such medicines. People living in the home had been treated with kindness and respect. One person stated that they liked living in the home because, “The carers here are very friendly and I feel I am amongst friends”. A visitor said, “Staff are respectful. They always knock on the bedroom door and wait before coming in”. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 13 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): Standards 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had been supported on the whole to achieve a lifestyle that met their needs and preferences. EVIDENCE: People living in the home who were spoken to and who responded to the survey indicated that they were satisfied with the arrangements for daily routines. “We can do what we want”. People described their daily routines and evidently were able to choose times for getting up and going to bed and similar routines. Positive comments were passed about the provision for stimulating activities. “I mostly watch television but there are activities if you want to join in”. “Activities, always full of fun”. One person was particularly pleased with the support they had received to pursue their painting hobby. Activities for stimulation and recreational had taken account of peoples’ abilities and needs. The home’s activity organiser spent sometime explaining this provision and showed the inspector a wide range of supplies for crafts, board games and Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 14 similar. The organiser was enthusiastic about her role and demonstrated understanding of the need to provide people in the home with activities for stimulation and entertainment. These had included, arts and crafts sessions, entertainers, karaoke, quizzes, bingo, fetes, fundraising, reminiscing, church visits, board games and themed events. A tuck shop had been introduced to enable peole to make small purchses ofgoods such as toilettries, sweets, writing materials. Comments about activities had remarked that there were few opportunities to go out of home, “Not much going on at Highfield for wheelchair bound people. Never see the outside of the building”. “Staff don’t appear to have time to push wheelchair outside ever or even into the garden in hot weather.” “ Very good activities within the home but last year had no outings. Year before went to Garden Centre etc. Would like outings”. A visitor to the home passed many positive comments about the service and said that they had been made welcome in the home. People described the catering service as “Very good”, “Marvellous”, “Excellent”, “The food is well done, I would like to congratulate the cook”. Records indicated that nutritional needs had been assessed. Special diets were catered for as required. The menus seen showed a nutritious choice throughout the day. A review of menus and the arrangement of furniture in the dining room had taken place since the last visit to provide an improved catering service. The inspector joined people for the mid-day meal. It was tasty and well cooked. The atmosphere in the dining room was congenial. The meal took place at an unhurried pace and was an enjoyable social experience. The cook and her assistant were aware of peoples’ needs and appetite, so that those who preferred smaller portions were not put off by larger servings of food. The cook was seen to go around the home to ask people about their preferences for lunch. She evidently was well known by the people living in the home and had established a good rapport with them. Members of staff were observed to provide sensitive assistance to those service users who were unable to feed themselves. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaints and protection procedures had enabled people to voice their opinions about the service and to protect them from abuse, EVIDENCE: Previous inspections had established that the home had satisfactory written complaints and protection procedures. Service users confirmed that they felt able to raise concerns. “I would tell anybody (staff)”. I would write it down or explain it to a team leader”. There were also regular service users meetings in which service users could comment on aspects of the service such as meals and activities. Minutes of frequent meetings were seen. Records indicated that the few complaints raised and been properly investigated and responded to. Three personnel files were assessed. Each contained records to show that robust recruitment practice had been followed that included the checking of employment history through references and checks via the Criminal Records Bureau and the Protection of Vulnerable Adults Register. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 16 Records indicated that staff had received briefing in protection procedures at twp recent staff meetings. Training in protection procedures had commenced and further training was scheduled. Staff spoken to demonstrated their understanding of protection procedures and their individual responsibility. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The layout of the building, its adaptations, décor and furnishings provided a suitable environment for frail older people. EVIDENCE: Feedback from people living in the home confirmed that they were satisfied with the comfort of their surroundings. One person described the décor as “bright and cheerful” and another wrote, “ The home is well kept, (no unpleasant smells). The soft furnishings are attractive, the colours and designs are of a good standard”. Areas of the building seen during the visit were clean and orderly. The décor throughout was mostly of a good standard. Given the numbers of people living and working in this building some, there was inevitably some deterioration brought on by wear and tear. Areas of the corridors required Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 18 repainting, paintwork/varnishing on doors and doorways were scratched and unattractive in appearance. The décor in the lounge used by those who smoked had deteriorated. The ceiling needed repainting. The carpet had been spoilt by many burn marks. The room would benefit from the installation of an extractor fan. Records and visual checks indicated that routine maintenance checks and servicing of equipment had taken place. Minutes of meetings showed that there had been briefing about the need for extra vigilance in procedures to prevent the spread of infection in relation to a recent outbreak of infectious disease. The home had sought the advice of health care professionals about these issues. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in the home had been well cared for by an experienced and committed team. EVIDENCE: The home’s staff team was an asset to this home. Members of staff on duty, care and ancillary, were observed to treat people living in the home with kindness and skill. In conversation with the inspector, members of staff showed empathy and commitment to those in their care. People using the service were complimentary about personnel. “The carers are very nice”. “Staff are lovely, really care about the residents”. “Staff listen and help us if they can”. “ The atmosphere at Highfield between the staff is very good. The result being a calm and happy situation whatever the difficulties rise”. A visitor was also positive about the team. “Staff are always kind and attentive, jolly residents along”. Information supplied by the provider showed that the majority of the care team, had worked in the home for a significant time and were well versed in the home’s day-to-day routines and the needs of people living in the home. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 20 The home employed sufficient ancillary personnel; administrative, catering, domestic, laundry and maintenance so that the care team could concentrate their efforts to meet peoples’ personal care needs. Rotas indicated that sufficient care staff had been rostered to care for the numbers of people living in the home. Given that a few people felt that staff were hurried in their roles, a review of the deployment of staff is suggested. A senior team was in place to support the manager and the team. Members of staff remarked that they felt well supported by the senior team, who were always available to provide guidance and reassurance if need be. Records indicated that the home had a comprehensive training programme. New starters undertook a detailed induction programme. In depth training/updates in key issues was provided to groups of staff throughout the year. Future training plans were also detailed and designed to maintain the skill level within the team as staff leave and new starters commence. The current level of staff with National Vocational Qualifications in care was 22.5 of the team. Recruitment procedures as outlined in section four were robust. Records indicated that equal opportunities procedures had been followed. External and internal applicants for jobs had completed written application forms, and attended for interviews, the results of which had been recorded. The records in relation to criminal records checks were not maintained fully at the home. The manager provided evidence of reference numbers for disclosures and their date of the issue after the inspection. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 21 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): Standards 31,32,33,35,36,37,38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home had been well managed to the benefit of all who lived, worked and visited the home. EVIDENCE: The manager evidently had high expectations of her staff and had sought and succeeded to guide them through her personal influence and role model. Staff spoke highly of the manager, her availability and support for the team. She was observed to have an excellent rapport with the people living in the home. They spoke highly of her role, “The home is marvellously run”, I am happy with the boss, she really helps you”, “She is really nice, always willing to listen”. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 22 The manager was approachable on an informal basis through her “open door policy”. Other more formal strategies were in place to consult with people living in the home and their relatives. The home actively encouraged feedback through a suggestion, compliments and complaints system. The report and action plan of the most recent quality assurance process carried out in December 2006 was seen. It showed a high percentage of customer satisfaction. Regular group meetings had been arranged for those living in the home. Few people living in the home held any of their personal monies. Relatives in the main held this responsibility and left small sums of money with the home for routine purchases. BUPA’s systems to manage monies held on behalf of service users are thorough. Records seen showed that small sums of money were held on site. Most purchases were for services such as hairdressing chiropody treatment, newspapers and similar. Records showed that transactions for income and expenditure had been well maintained. Records and discussions with personnel indicated that they had received supervision but there had been some recent problems due to staff shortages to maintain the frequency of these meetings. There had however been group meetings to update and brief staff as required. Systems to manage health and safety throughout the home were also thorough. The corporate procedures were detailed, as were risk assessment and safety monitoring systems. Information provided pre-inspection showed that equipment had been regularly serviced and maintained. This was confirmed during the inspection by visual checks. Records indicated that staff had received appropriate training in safe working practices. Practice observed showed that members of staff were aware of safe practice in relation to moving and handling, infection control, administration of medicine and food hygiene. Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 x 3 2 2 3 Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 24 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 OP37 Regulation 17 Schedule 2 Requirement The registered person must maintain evidence in the home to demonstrate that Criminal Records Disclosures have been obtained for all personnel. Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 1. 2. OP12 OP19 People living in the home should be provided with opportunities to take recreational trips out of the home. The ceiling to the lounge used by those who smoke should be redecorated and the carpet to this room should be replaced. The room should also be fitted with an extractor fan. A review of the deployment of staff should be carried out to ensure that members staff are available to responds to requests for assistance in a timely fashion. 3. OP27 Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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. Extracts may not be used or reproduced without the express permission of CSCI Highfield DS0000014912.V334824.R01.S.doc Version 5.2 Page 26 - 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. 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