Inspection on 06/04/09 for Highview

This inspection was carried out on 6th April 2009.

CQC 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 CQC 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

Highview 14/04/08

Highview 26/07/07

Highview 06/09/06

Highview 18/03/06

Highview 10/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Highview 284-290 Great Clowes Street Higher Broughton Salford Gtr Manchester M7 2HD Lead Inspector Adele Berriman Key Unannounced Inspection 6th April 2009 09:30 DS0000064499.V374803.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Highview Address 284-290 Great Clowes Street Higher Broughton Salford Gtr Manchester M7 2HD 0161 792 2610 0161 792 6763 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) Highview Residential Limited Care Home 35 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (22), Physical disability (1) Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The category DE is for two named individuals under 65 years of age. If either of these people leave, the service user category will revert to OP. The dependency levels of service users must be assessed on a continuous basis and staffing levels adjusted, where appropriate, to ensure continued compliance with the Residential Forum Guidance in Care Homes for Older People. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The category PD is for the named individual under 65 years of age. If this person leaves, the service user category will revert to OP. 14th April 2008 3. 4. Date of last inspection Brief Description of the Service: Highview is a residential home providing care, support and accommodation for up to thirty-five older people. Of these twenty-five people require personal care only and ten people have dementia and require personal care. Highview Residential Ltd owns the home and at the time of the visit there was no manager registered with the Commission. The home occupies an elevated position off Great Clowes Street in Salford. Access is to the rear of the building via a level access route, which leads to the main entrance/reception area. Parking is available to the rear of the building. The front of the building provides an enclosed patio seating area for residents. Accommodation is provided on three floors, which are all serviced by a passenger lift. There are 32 single bedrooms, 6 with en-suite facilities and 3 double bedrooms. The cost of the service is between £325.87 and £373.52 per week. Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that people who use the service experience adequate quality outcomes. As part of this key inspection we carried out an unannounced visit to Highview on Wednesday 8th April 09 and we arrived at 10am. The visit last for approximately eight hours. During our visit we looked at documents including a selection of care plans, staff files, polices and procedures. We spoke to four people who live at Highview and one of their relatives, the manager and three members of staff. Prior to our visit the manager had completed an Annual Quality Assurance Assessment (AQAA). This document gave them the opportunity to tell what they thought they did well, how they felt they had improved over the last 12 months and their plans for improvement in the next 12 months. Two people who live at Highview completed a survey form to tell us their thoughts on life at the home. One person had completed their form with the assistance of a friend and the other person had been assisted by a member of staff. Seven staff completed survey forms to tell us their experiences of working at Highview. They had received no formal complaints about the service since we last visited. Positive comments were made about the staff and the manager of the service. These comments included “always very good to me” and “the manager is very approachable.” What the service does well: People told us that they knew how to make a complaint about the service if they were not happy. Staff were observed supporting people in a manner that supported their privacy and dignity. An open visiting policy gave people the opportunity to visit the service at any time. People had regular access to healthcare professionals. Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefited from having their needs assessed prior to moving into Highview to ensure that the home has the facilities to meet their needs. EVIDENCE: We saw that people’s needs were assessed prior to moving into the home. The purpose of the assessment was to ensure that the service was able to meet all the needs of the person. The manager told us that either she or the care supervisor would carry out the pre-admission assessment. Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 9 Information gained during the pre-admission assessment was recorded on a set format that gave the opportunity to record people’s specific needs and wishes related to their day to day living. Since we last visited Highview, the service have introduced a new format to record information gained during the assessment. Pre-admission assessments were present on all four of the care plan files that we looked at. Highview does not provide intermediate care facilities. Highview DS0000064499.V374803.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To ensure that people’s needs are fully demonstrated records and risk assessments that form part of the care planning process should completed and reviewed on a regular basis. EVIDENCE: Since we last visited the home they had introduced a new care planning system. They were in the process of transferring all care planning documents onto the new format. The majority of the care plans were still on the old format. We looked at two care plans on the new format and two on the existing format. It was evident from the paper work available to us that actions had been taken to improve the care planning process within the home. As they were in the Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 11 process of transferring information we saw that some documents contained more information than others. We saw some detailed information about people’s needs, for example, one bathing record told us that the person required the support of ‘one care assistant to assist with washing legs and feet and that the person could sequence washing their face and upper body and that they required assistance with dressing the lower body.’ However, the majority of the new care plans that we saw were still in the process of being completed. It is essential that a detailed up to date care plan is available at all times to ensure that people’s needs can be met. We saw that each person had their own individual personal file which contained their care plan, personal information and correspondence. We saw that care chart record sheets were available for recording when people had received or had been offered personal care. Not all of the information that we saw on these records was up to date. For example, one record had not been completed since the 18th January 09. A detailed record of all care offered and delivered to individuals’ should be maintained at all times to ensure that people receive the care and support they require. Individual risk assessments formed part of people’s care plans. We saw risk assessments that considered moving and handling, falls, nutritional risk assessments and pressure area risk assessments. We saw one risk assessment that had been wrongly calculated: this gave inconsistent information about the persons needs within their care plan. Not all of the risk assessments on the new care planning format had been completed. All identified risks for individuals must be assessed and reviewed on a regular basis to ensure that any risk of harm can be minimised. Both people who completed a survey form told us that they receive the care and support they need. One person told us that ‘they thought it was a very good place.’ Policies and procedures were available for the safe management and administration of medication. Since we last visited two new medication cabinets and a controlled drugs cabinet had been installed. They told us that the manager, the senior carers and some of the care staff were in the process of completing a ‘managed care training programme’ to enable care workers to safely administer medicines in the care home. They told us that the training was a distance learning course that was linked to the pharmacy that supplied the home. Medication was recorded on pre printed MAR (Medication Administration Records) sheets. Those that we looked at were completed appropriately. We saw that several people were in receipt of medication for occasional use (PRN medication). We saw no information recorded about when the PRN Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 12 medication should be administered. To ensure that people receive their medication when it is required detailed information should be recorded as to when and how PRN medication should be administered. Throughout the visit we saw staff supporting people in a polite and dignified manner. Highview DS0000064499.V374803.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People would benefit from having more activities available to meet their cultural and recreational needs which could provide periods of stimulation. EVIDENCE: We saw that no formal programme of activities was available at the time of our visit. The two people who completed survey forms told us that there were sometimes activities arranged by the home for them to take part in. Three staff told us in their survey forms that they thought the availability of activities could be improved. One staff member told us that activities could be improved for people with dementia and another member of staff told us there should be more “activities such as outings and more games.” We saw several games available around the home, however, during our visit we saw no evidence of an activities taking place. The manager told us in the Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 14 AQAA that they planned over the next twelve months to provide outings for people. To ensure that individuals’ needs are fully met, people living at Highview should have access on a regular basis to activities that satisfy their social, cultural, religious and recreational interests. They told us that visitors were welcome at any time. We spoke to one relative who was visiting the home who told us that they were always made welcome, that they were happy with the staff and that “the manager is very approachable.” Both people who completed surveys forms told us that staff listen and act on what they say. One person wrote “staff are very good to me.” We saw evidence on people’s personal files of information on how they could contact an independent advocacy service. Meals were served in the dining areas around the home. They told us that if a person wished to have their meal in their room they would be supported to do so. A four weekly menu was in place that demonstrated that people had a choice of a cooked meal at lunchtime. The menu did not give a choice for the teatime meal. It is important that people have a choice of foods served at teatime to ensure that people maintain a good dietary intake. People’s opinions about the food served at the home were mixed. Two people told us that they sometimes liked the meals they were served and one person told us that they had “good meals.” One person told us during our visit that “the food is always cold and there is no choice.” Highview DS0000064499.V374803.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems were in place to protect people. EVIDENCE: We saw that a copy of the homes complaints procedure was available in people’s bedrooms. The document was in need of updating as some of the information about who to contact was out of date. To ensure that people are aware of who to contact regarding a complaint, up to date information should be available at all times. They told us that no formal complaints had been made about the service since we last visited. The two people who completed a survey form told us that they usually knew who to speak to if they were not happy about something and both told us that they knew how to make a complaint. Staff told us in their survey forms that they knew what to do if a person had a concern or a complaint about the service. We spoke to a visiting relative. They told us that they knew how to raise a concern or a complaint about the service. They told us that they had raised a concern in the past and that it had been dealt with by the manager and that Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 16 they were happy with the way that the concern was managed. They told us “the manager is very approachable.” During our visit a member of Salford Social Services safeguarding team was holding a discussion session with the staff about the Deprivation of Liberty of people (DOL’s) and the recent legislation and guidance surrounding the subject. After the session staff told us that they thought the session was very useful and informative. A copy of Salford Social Services joint agency safeguarding procedures was available at the home. In addition, the manager was in the process of implementing a new policy for the protection of vulnerable people. Since we last visited staff at the home had raised several concerns under Salford Social Services Safeguarding procedures. We saw no evidence that staff had received awareness training local safeguarding procedures. All staff should have the opportunity to receive this training to ensure that they are all familiar with the process of reporting safeguarding concerns. Highview DS0000064499.V374803.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will benefit from the planned refurbishment of the home. EVIDENCE: We looked at some areas of the environment. We saw that a carpet had been replaced as required in the previous report. We saw that several bedrooms and corridors had been redecorated and the manager told us that the lounge and dining rooms on the ground floor would be redecorated within the next few weeks. Other rooms were seen to be in need of redecoration and the manager told us that they were prioritising what areas of the home needed refurbishing. Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 18 We looked at several people’s bedrooms during our visit, most of which contained people’s personal effects which individualised the rooms. A part time maintenance person is employed at the home to carry out general maintenance throughout the building and to check the fire detection systems and hot water temperatures on a regular basis. On the day that we visited the manager had a pre-arranged visit from Salford City Council Environmental Health department. The manager explained that she was in the process of trying to give the home the opportunity to participate in the city’s re-cycling programme. During the visit the home was seen to be clean and tidy. There was an odour present in the entrance hall of the building and the manager told us that she was trying different ways in which to remove the odour. Both people who completed a survey form told us that the home was sometimes fresh and clean. Highview DS0000064499.V374803.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in the home are not always supported properly by the homes recruitment practices. EVIDENCE: At the time of the visit we saw that there were three carers, a senior carer and the care supervisor on duty to meet the needs of the 22 people in residence. We observed staff supporting people in a manner that demonstrated they were fully aware individuals’ needs and wishes. One person who completed a survey form and people who we spoke to during our visit told us that staff were sometimes available when they needed them. Staff told us in their surveys that there were sometimes enough staff available to meet the needs of the people who use the service. A regular review of the number of staff available should take place to ensure that people’s needs could be met at all times. The manager of the service demonstrated to us a good awareness of appropriate recruitment procedures. Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 20 We looked at the recruitment files of four staff members. We saw that the majority of the information required was contained on the file. We saw that letters had been sent to the staff team by the manager to request further information from them to ensure that all of their records were complete and up to date. Several staff had responded and supplied the relevant information. However, several documents were still outstanding, for example, proof of identification. It is essential that detailed records of all staff must be maintained at all times. The manager of the service demonstrated to us a good awareness of appropriate recruitment procedures. Information supplied to us by the manager demonstrated that the majority of staff had achieved or were working towards their National Vocational Award (NVQ) level 2 or 3 qualification. We saw a training matrix that demonstrated that several staff had not received training in the protection of vulnerable adults, health and safety, fire training and infection control. The manager told us that she was in the process of arranging training opportunities for staff, by arranging training within the home as well as recently joining Salford Training Partnership which will enable them to access training events. We saw several staff files that contained evidence of training sessions that they had attended. The training included manual handling and accredited training in medicines in care homes. Staff told us in their survey forms that they were being given training that was relevant to their role, that helped them understand and meet the individual needs of people and that keeps them up to date with new ways of working. One staff member told us “I am starting a customer care course which will help me meet the needs of people in my care. The manager has bought DVD’s for training in mental capacity, first aid, care planning, health and safety and food hygiene.” During our visit another member of staff told us that ‘changes were happening in the home’ and that she was about to start a customer care course. Highview DS0000064499.V374803.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A manager registered with the Commission would promote consistency within the home. EVIDENCE: The manager of the service had been in post for approximately six months. She demonstrated to us that she had a good awareness of what improvements were needed around the service and had a good knowledge of the management role in a social care environment. Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 22 It was of concern that there had not been a manager registered with the Commission for some time. A requirement has been made in this report that an application is made for a person to be registered as the manager of Highview. Prior to our visit the manager completed an Annual Quality Assurance Assessment. This document gave them the opportunity to tell us what they do well, what improvements had been over the previous 12 months and their plans for improvement in the next 12 months. The AQAA contained most of the information we asked for. They told us that they had a quality assurance system in place. They told us that surveys would be sent to people to ask their views on the service they receive and they were anticipating that the first set of survey would be distributed and retuned by June. The manager told us that following the outcomes of the surveys a development action plan would be created. They told us that to assist with the quality monitoring at Highview a resident’s meeting had taken place the week prior to our visit and further meeting were planned throughout the year. The manager told us that she also planned to have a relatives meeting to gain their views on the service. We saw that a system was in place for the safe management of resident’s personal finances. We saw that a detailed policies and procedures manual that contained information relating to health and safety, recruitment and aspects of care practices had been obtained since we last visited. The manager told us that she was in the process of implementing the policies and procedures within the home. Highview DS0000064499.V374803.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Highview DS0000064499.V374803.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 OP7 Regulation 15 Requirement To ensure that people receive the care and support they require all care plans and related risk assessments must contain detailed and up to date information. To ensure that people receive their medication when required detailed information regarding when and how PRN medication is to be administered should be gained from the prescriber and a detailed record maintained. All staff files need to contain all the information required under Schedule 3; to ensure that all actions have been taken to minimise the risk of unsuitable people being employed. Timescale of 07/09/07 not met. An application must be made to the Commission for the registration of a registered manager. Timescale for action 30/07/09 2. OP9 13 30/07/09 3. OP29 19 30/07/09 4. OP31 9 04/08/09 Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP9 Good Practice Recommendations A detailed record of all care offered and delivered to individual’s should be maintained. The pre admission assessment should give the opportunity to record peoples social, cultural and religious needs. People should have the opportunity to have access to activities that satisfy their social, cultural, religious and recreational interests. The complaints procedure should be reviewed to ensure that it contains the correct details of who people can contact in the event of having a complaint or concern about the service. All staff should have the opportunity to attend awareness training on local safeguarding procedures. A regular review of the number of staff available throughout the home should take place to ensure that sufficient staff are on duty to meet the needs of people. 3. OP12 4. OP16 5. 6. OP18 OP27 Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Highview DS0000064499.V374803.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!