Inspection on 10/10/06 for Hillingdon House

This inspection was carried out on 10th October 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

Hillingdon House 05/11/08

Hillingdon House 02/07/07

Hillingdon House 30/01/06

Hillingdon House 18/02/05

Hillingdon House 15/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Hillingdon House 170-172 Ashby Road Burton On Trent Staffordshire DE15 0LG Lead Inspector Rachel Davis Key Unannounced Inspection 10 October 2006 10:30 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 Hillingdon House DS0000004958.V310693.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. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillingdon House Address 170-172 Ashby Road Burton On Trent Staffordshire DE15 0LG 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) 01283 510274 F/P 01283 510274 Mrs Jean Ann Miles Miss Joanne Louise Miles Mrs Jean Ann Miles Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 PD minimum age 60 yrs Date of last inspection 30th January 2006 Brief Description of the Service: Hillingdon House is a residential care home offering 21 places for older people; it is not registered to support people with dementia. It may accommodate one person under 65 with a physical disability. Hillingdon House consists of two neighbouring Victorian properties; one houses 14 residents, the other 7. It is situated in a residential area of Burton-upon-Trent, affording residents the opportunity of maintaining links with the neighbouring community. It is well placed for the town centre and has the facility of a main bus route. Both the exteriors and the interiors of the properties are well maintained; they are both very clean and the décor is set to a good standard. The residents are offered easy access to all areas of the home by the use of grab rails and a lift. All bedrooms meet the required sizes set out by the national minimum standards and are equipped with suitable fixtures and fittings. The bathrooms and toilets are well located and offer appropriate equipment and facilities. Communal areas are spacious and comfortable; patio areas with seating are available and easily accessed. Hillingdon House charges its residents between £320 and £365 per week; this information was accurate on 25/09/06. Mrs Jean Miles is the registered manager and the proprietor. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 10/10/06. This visit was a key inspection and therefore covered all of the core standards. The inspection included an examination of records, direct observation of care staff, and discussions with residents, the deputy manager, registered manager staff and visitors. The pre-inspection questionnaire was sent to Hillingdon House by the Commission for Social Care Inspection at the beginning of August 2006, this has been completed and returned by the home in September. Evaluations from feedback received in questionnaires sent by the Commission are included within this report. People living at Hillingdon House are referred to as residents throughout this report, except under the regulations where they are referred to as service users. Twenty-one residents were in accommodation at the home on the day of inspection. Two residents files were examined and 2 staff files were seen, including recruitment records. Three members of staff were spoken with, as were a number of residents, visitors and a visiting professional. A partial tour of the building was undertaken. During the inspection process both the registered manager and the deputy manager assisted the inspector in providing the relevant information and documents required. One serious concern was identified during this visit, the content of which is within this report. Twelve requirements and three recommendations were made as a result of this inspection. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The recording of complaints has much improved and a grumbles/ comments book is now in place. The home can also evidence how these concerns are followed through with recorded outcomes. Since the last inspection there have been 2 complaints made directly to the Commission for Social Care Inspection regarding the amount of protective gloves provided at Hillingdon House. Practice has now changed and the registered manager and staff confirmed that this was no longer an issue. The registered manager has removed the two door wedges as required and provided suitable magnetic catches where necessary. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 7 The home continues to improve their risk assessment records but this still requires expansion. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hillingdon House DS0000004958.V310693.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 Hillingdon House DS0000004958.V310693.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is “good”. This judgement has been made using available evidence, including a visit to this service. Residents’ individual needs are assessed when first moving to the home and are re-assessed on a regular basis thereby ensuring that their health, welfare and social needs are fully met. EVIDENCE: A sample of residents were interviewed, and two relatives. There was evidence from speaking to staff, and observing care practices and documentation, that residents needs were identified by an assessment process, and subsequently met. Two residents files were examined and again there was evidence within these files to demonstrate that the residents’ needs had been assessed prior to their admission this process allowed the home to determine if they were able to meet the need. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 10 The home does not provide intermediate care; therefore standard 6 was not assessed. Hillingdon House DS0000004958.V310693.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. Overall residents health, personal and social care needs were met. Further development of the homes risk assessment practices and selfmedication administration records are required to ensure residents’ safety is maintained. EVIDENCE: Two residents files were examined and both demonstrated that care plans had been developed following an assessment of residents needs, including risk assessments, although these were not always up to date. The home must ensure that when a risk assessment identifies that two staff are required to transfer this is carried out in all instances, not doing so leaves both the staff member and resident vulnerable. Some residents spoken with were not as satisfied as others and comments like: Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 12 “ It isn’t as good as it was.” “Some staff are better than others” and “It makes me despondent” were said. It was noted that the recording of daily records had ceased since the last inspection; this needs to be reintroduced without delay. Evidence within the files seen demonstrated that residents were consulted about the care provided to them whenever possible. All residents were designated a key worker and care plans were generally reviewed on a monthly basis and this was documented within the resident’s files seen. Some residents that were spoken with were very positive about the care provided at the home and one resident stated that – “The staff are always polite and knock before entering my room.” Another said, “ I am very happy here, it’s lovely.” One resident had written on their questionnaire “I get every care very happy.” Residents had access to a wide range of health care services according to their individual need and assessments were in place that looked at residents’ tissue viability, pressure areas, nutritional needs, continence needs, hearing and sight. A visiting professional confirmed that “ appropriate referrals are made, and that they had no problems with the home.” It was noted that none of the wheelchairs in the home had footplates attached. A wheelchair must always have these in place to ensure safe transportation throughout the home; not doing so potentially puts a resident at risk Medication practices were examined this included the medication trolley, and some of the medication administration records. These were found to be in order. One resident chose to self-administer their medication and the respective resident had signed a declaration. However no risk assessment was in place, any resident who chooses to self administer any of their medication must have an assessment, this ensures that the residents’ physical and mental capacity to undertake self administration is assessed, thereby ensuring residents’ safety is maintained. Residents had access to a pay phone for outgoing calls and some of the residents at the home had chosen to have their own telephone line within their private accommodation. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 13 Visiting hours at home were open, some of the residents spoken with said they often went out with their families on a regular basis. Information regarding the residents wishes on death and dying were in place within the 2 files seen and demonstrated that the resident or their representative were consulted regarding this. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 14 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, 13, 14 and 15. Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. Residents were supported and enabled to exercise their right to make their own decisions and choices. Residents maintained contact with family and friends as they wished. The variety of meals provided by the home could be more varied, however they were wholesome ensuring a good nutritional content was maintained and choices were available to suit residents preferences and dietary needs. EVIDENCE: Residents that were spoken to were very positive about the activities provided and felt the home offered plenty of activities for them to join in with if they wished. The home also provides a newsletter that is made available to everyone on the notice board. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 15 Residents were able to receive visitors whenever they chose, as the home had an open visiting policy. Residents could choose to see their visitors within their own private accommodation if they preferred to do so. The residents spoken with confirmed this. Residents also revealed they were able to come and go freely and one said, “There are no restrictions.” One resident spoken to liked to stay in their own room and also take meals there, another was just doing so on that day. These findings confirm that residents are offered a flexible routine that are varied to suit individuals expectations and preferences. The kitchen was inspected and found to be clean and tidy. Food supplies were plentiful and fresh fruit and vegetables were available. Records of fridge and freezer temperatures and probing were kept. The home must supply food labels and probe wipes. Opened jars in the fridge which need to be consumed within a timescale had not been labelled and the home must talk with residents who may require aids and adaptations, for example plate guards, as none were available. A new cook had commenced on the day of inspection and all of the residents spoken with were very complimentary about the meal provided, the Commission can confirm that a choice is also offered daily. Questionnaires and discussion denoted that a larger range in meals needs to be provided. “ Not much variety.” “Sometimes repetitive,” were comments received. This was discussed with the registered manager who had also identified this need and confirmed it would be addressed. Information to assist in menu planning was provided by the Commission. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. The homes complaints procedure now ensures that residents and their representatives can be confident that their complaints or concerns will be acted upon. Not all staff had received training in The Protection of Vulnerable Adults. Recruitment procedures are not robust and therefore do not fully protect residents. EVIDENCE: The Commission for Social Care Inspection has received two complaints regarding the home since the last inspection held in January 2006. The registered manager has made a change in practice and dealt with these with appropriately. These two complaints referred to the same issue, that wasinsufficient quantity of protective gloves. This is now resolved and confirmed by the staff team on duty on the day of inspection to the Commission. The home has not received any formal complaints from residents or their relatives since the last inspection. It was pleasing to note that a grumbles and comments book has been put in place which records issues that may refer to food, clothing, heating etc or other issues that will assist the registered manager in providing a “service user focused” and “open and transparent” service to the residents. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 17 Staff are made aware of Adult Protection procedures and how to manage allegations and complaints but it was difficult to ascertain the numbers of staff who have received training in this area as records were currently being updated. However, with the large turnover of staff recently it is inevitable that a number of staff will require training in this area. One member of staff spoken with was unaware of the Whistleblowing Policy; it is recommended that the policy be revisited. Recruitment procedures are referred to and evidenced under Staffing. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 18 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, 21, 24 and 26. Quality in this outcome area is “excellent”. This judgement has been made using available evidence, including a visit to this service. The home is well maintained and good standards of hygiene are kept this ensures the residents comfort and safety. EVIDENCE: A partial tour of both the buildings was undertaken and several residents’ private accommodation was seen along with two bathrooms, the dining rooms, conservatory, and the laundry and kitchen area. The home is safe and well maintained with adaptations to suit residents’ specific needs. It is decorated and furnished to a good standard that creates a comfortable and homely environment. It was fresh and clean throughout on the day of the site visit. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 19 The bathrooms provided sufficient moving and handling equipment for those residents who required assistance and support. The laundry and kitchen were kept in good order. Residents spoken with and questionnaires returned confirmed that the home was always clean and tidy. The residents’ private accommodation seen was kept to a high standard of cleanliness, it also reflected individual residents personalities and preferences. The home employs a maintenance person who carries out any required maintenance on an ongoing basis. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 20 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 and 29 Quality in this outcome area is “poor”. This judgement has been made using available evidence, including a visit to this service. The information currently held on staff files is insufficient to ensure that residents are fully protected by the homes recruitment procedures. There are not always adequate numbers of staff on duty to meet the needs of the residents. EVIDENCE: The number of staff on duty during part of the inspection was not satisfactory to meet the needs of the residents within the home. The rotas seen confirmed that this was not an isolated incident. On the day of inspection there were only two staff on duty between the hours of 15:00-18:00, this occurred on rotas too, but not always for a period of three hours; sometimes it was for one or two. When a resident requires the assistance of two staff (as is presently the case) it is not acceptable that the other 20 residents are left without suitable and sufficient staff. The registered manager must ensure three staff are available at all times and demonstrate appropriate levels of support during the night. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 21 Two staff files were viewed. One file only had one reference in place but they had also commenced work 5 days before the home had applied for this. The legal requirement is for two references to be in place, this is also a previous requirement which remains unmet. Both files contained incomplete application forms; the registered manager must receive a full employment history from prospective employees and has a duty to explore any gaps in these. One employee had stated she had training in a number of areas for example moving and handling, basic food hygiene but there were no certificates to corroborate this. In one file interview records were found in the other incomplete induction records, documentation was not consistent in the files, for example only one file contained a progress record but it had not been completed. It was revealed during the inspection process that 5 staff working at Hillingdon House did not have Protection of Vulnerable Adult (POVA) First Checks. An immediate requirement to apply for this was made. This is of serious concern, as vulnerable people are not being fully protected due to the homes poor recruitment procedures. On the day of inspection the deputy manager was in the process of organising the staff training matrix and identifying necessary training needs, this was not seen by the Commission and will be addressed at the next inspection. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 22 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, 33,35, 37 and 38. Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. An experienced manager manages the home and offers leadership. Additional health and safety risk assessments need to be completed to ensure that the residents and staff are as safe as is reasonably practicable. Some financial records need to become more robust again to protect staff and resident. EVIDENCE: Residents spoken to were satisfied with the home, comments made included: “ I have nothing to complain about” Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 23 “ I like it here” “ We are very happy.” Staff spoken with confirmed that the manager had an open and transparent approach to running the home and stated that if they had any concerns or questions they could speak with the manager at any time. The home are presently using a communication book inappropriately, this was discussed with the registered manager at the time of the visit and in future will be used in a way that complies with Data Protection legislation. Fire risk assessments were in need of completion; presently an up to date audit is in place. The manager is aware that she must complete a written contingency plan in the event of a fire or bomb threat regarding safe placement of residents. The manager must also liaise with the fire officer to discuss intumescent smoke and fire strips, compartmentalisation, individualised evacuation and any other requirements necessary to meet with new fire regulations. The health, safety and welfare of staff and residents are as far as reasonably practicable protected. Residents were able to keep small amounts of money within the home and lockable facilities were available within the resident’s private accommodation for safe keeping of monies or personal belongings. The also provided a secure facility for residents monies if required. Cheque transactions were not recorded; this prohibits staff, residents and relatives from having accurate information regarding all financial transactions. Signatures and receipts need to be seen, as a matter of good practice it is advisable that two people sign on each transaction, preferably one of these being that of the residents if they are able to do so. Evidence was in place to demonstrate that the emergency lighting and fire alarms were checked within the required timescales. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 24 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 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X 4 X X 4 X 3 STAFFING Standard No Score 27 1 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 25 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 OP18 Regulation 19(1)(b) Requirement The responsible individual must ensure that a Protection of Vulnerable Adults (POVA) First is in place prior to employment for all staff. Immediate Requirement. The registered person must ensure daily records are in place for all service users within their plans of care. The registered person must ensure that service users who choose to self-administer their medication are assessed to ensure they have the capacity to do so. The registered person must provide food labels, probe wipes, and any specialist equipment if required. The registered person needs to ensure that food products are dated when opened if necessary. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working in the care home in such numbers that are appropriate for DS0000004958.V310693.R01.S.doc Timescale for action 17/10/06 2 OP7 15 31/10/06 3 OP9 13(2) 17/10/06 4 OP15 16(2)(g) 31/10/06 5 OP27 18(1)(a) 17/10/06 Hillingdon House Version 5.2 Page 26 6 OP29 7 OP29 8 9 OP34 OP37 10 OP38 11 12 OP38 OP38 13 OP38 the health and welfare of service users. 18(4)(b) i The registered person must ensure all members of staff are in receipt of two written references. Previous requirement not met Schedule2 The registered person must (6) ensure all documents required under Schedule 2 are in place The registered manager must ensure all gaps on application forms are explored around the applicant’s employment history. 17(2) The registered person must Schedule ensure robust systems are in 4 (9) place for all financial transactions 17 The registered person must ensure their practices comply with Data Protection, in this instance the communication book. 13(4)(b) The registered person must ensure footplates are attached to wheelchairs when transporting service users 13(4)(a) The registered person must ensure further building risk assessments are implemented 24(4)(c)(ii The registered person must liaise i) with the fire officer to ensure compliance with new fire regulations. Schedule The registered person must 4 (15) complete a written fire risk assessment and a contingency plan in the event of a fire or bomb threat regarding safe placement of service users. 31/10/06 10/11/06 31/10/06 17/10/06 17/10/06 10/11/06 10/11/06 10/01/07 Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 27 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 OP18 OP37 OP38 Good Practice Recommendations The registered person should revisit the Whistleblowing Policy to verify the staffs’ understanding. The registered person should look at further ways of evidencing how they meet the diverse needs of the service users. The registered person may wish to add information in the Statement of Purpose to reflect the possible implications of the new Fire Regulations, which come into force in October 2006. Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Hillingdon House DS0000004958.V310693.R01.S.doc Version 5.2 Page 29 - 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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