Inspection on 10/11/06 for Holmewood EMI Resource Centre

This inspection was carried out on 10th November 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 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

Holmewood EMI Resource Centre 18/10/07

Holmewood EMI Resource Centre 09/03/06

Holmewood EMI Resource Centre 11/08/05

Holmewood EMI Resource Centre 15/03/05

Holmewood EMI Resource Centre 13/07/04

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

CARE HOMES FOR OLDER PEOPLE Holmewood EMI Resource Centre 67 Fell Lane Keighley West Yorkshire BD22 6AB Lead Inspector Mary Bentley Key Unannounced Inspection 10 & 13 November 2006 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 DS0000033522.V313916.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. DS0000033522.V313916.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmewood EMI Resource Centre Address 67 Fell Lane Keighley West Yorkshire BD22 6AB 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) 01535 602997 01535 691095 mary.petty@bradford.gov.uk City of Bradford Metropolitan District Council Department of Social Services Care Home 32 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (30) of places DS0000033522.V313916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2006 Brief Description of the Service: Holmewood Resource Centre is situated in a residential area of Keighley about one mile from the town centre. The home is on a main bus route and parking is available at the front of the property. The home is run by the Local Authority and provides long-stay, short stay and respite care for people with a diagnosis of dementia or a dementia type illness. The resource centre also has a day centre and an outreach service; day care is not regulated and this inspection only involved the residential services. Care is provided on two floors, in four separate units (three long-stay) each with a designated staff team. Each unit has a communal lounge/dining room, and toilet/bathroom facilities are conveniently located throughout the building. A ramp provides disabled access to the front door. The home has a passenger lift to the first floor. The home stands within its own grounds and there is a sensory garden for the residents to enjoy during the summer months. In October 2006 the provider told us the weekly fees range from £90.65 to £435.68; hairdressing and chiropody are available at an additional cost. DS0000033522.V313916.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 we made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection was done in March 2006 and we have not made any additional visits to the home since then. Since the last inspection the home has had a change of management. The purpose of this inspection was to look at how the needs of people using the service are being met and to assess the impact of the management changes on the service. The methods used in this inspection included looking at care records and other paperwork such as staff and maintenance records, talking to residents, visitors staff and management, observing care practices in the home and looking at some parts of the home. The home completed a pre-inspection questionnaire and the information provided was used as part of the inspection. The people who live at Holmewood were unable to complete comment cards because of the nature of their illnesses. We contacted a number of relatives before the visit and sent comment cards to other professionals involved with the home. Overall people were satisfied with the service and the information they provided has been included in the report. One GP described the home as “the jewel in the crown”. The inspection was unannounced; it was carried out on 10 and 13 November 2006 and in total I spent 11.5 hours in the home. At the end of the visit I discussed the main findings of the inspection with the manager. One issue of immediate concern was identified during the inspection, this related to problems with the hot water supply. The senior management of the home have assured us that this would be dealt with as a matter of urgency. Since the inspection the organisation has been working hard to resolve the problems with the hot water supply. They have agreed to replace the existing system with a new installation and this is scheduled to happen early next year. DS0000033522.V313916.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home needs to do some work on the new care plan format to make sure that staff are given clear and detailed information about how to meet residents needs. The programme of social activities has lapsed over recent months and the home must now address this so that residents are supported in spending their time meaningfully. The home should review the practice of routinely keeping bedroom doors locked so that if residents wish they can have access to their bedrooms during the day. This would also make it easier for people to see their visitors in private. DS0000033522.V313916.R01.S.doc Version 5.2 Page 7 The organisation must look at how it responds to serious maintenance issues so that problems such as those with the hot water supply are dealt with quickly in the future. Seven requirements have been made about these and other issues identified during the inspection. 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. DS0000033522.V313916.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 DS0000033522.V313916.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): 1 & 3. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home does not accept new residents until they have done a detailed assessment of the person’s needs and are satisfied that they can meet those needs. EVIDENCE: The home is updating the Statement of Purpose and Service User guide to take account of recent changes such as the change of management. Holmewood has a day centre and a respite unit as well as three units for longterm care. In the majority of cases people who move into long-term care have already had contact with the home through the day care or respite care services. People who are new to the service are encouraged to visit the home before making a decision about admission. DS0000033522.V313916.R01.S.doc Version 5.2 Page 10 The management team are very clear about the admission criteria. The preadmission process is thorough. As well as looking at the needs of the prospective resident the management team consider the needs of existing residents and the resources available within the home to meet the assessed needs. DS0000033522.V313916.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Despite some shortfalls in the care records residents’ personal and health care needs are met in a way that respects their privacy and dignity. Residents are protected by the home’s systems for dealing with medicines. EVIDENCE: I looked at the care plans of three residents. The home is changing the format of the care records and the care plans I looked at contained both the old and the new paperwork. Therefore, it was very difficult to get a clear picture of people’s needs. Staff said they had received little or no training on how to use the new paperwork and were finding it difficult. There was some good detail about people’s needs and abilities in the old care plans. It is important that staff are trained in using the new system so that this information is not lost. The new format does not have a section on each DS0000033522.V313916.R01.S.doc Version 5.2 Page 12 page to record the resident’s name so personal information could be misplaced. The care instructions page does not include a section for recording the date or the name of the person writing the care plan. Care reviews usually take place six weeks after admission and once a year after that. A number of relatives, of residents that have been in the home for some time, confirmed that they had been involved in these reviews. However, the records showed that six-week reviews had not taken place for two residents who were admitted earlier this year. The majority of relatives said they were kept well informed by the home. Most relatives were very happy with the care being provided; one person said their relative was “remarkably well looked after”. Residents have access to a full range of health care services through their GPs. Three health care professionals completed comment cards; they all said they were satisfied with the care provided at Holmewood. Because of the problems with the hot water supply bathing routines have been disrupted. However, staff have made sure that residents are helped to wash thoroughly and all the residents looked clean and well groomed. Care staff are responsible for helping residents with their medicines. All the staff have had training from the pharmacist on how to use the medicine system. Eight staff are enrolled on an advanced medicines course at Keighley College, the intention is that all staff will attend this training. None of the residents manage their own medicines. DS0000033522.V313916.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. More attention must be given to making sure that residents have the opportunity to take part in varied social activities that reflect their needs, preferences, and abilities. The home has flexible daily routines and this helps residents to have some control over how they live their lives. Overall the home supports residents in keeping in touch with their families and friends but opportunities for visits to take place in private are limited. EVIDENCE: The layout of the home helps to promote flexible daily routines. Each eightbed unit has a dedicated staff team and they are able to get to know the residents well. Residents can walk about freely between the units and choose which lounge to sit in. Residents and staff were clearly comfortable in each others company and conversations between them were relaxed. Many relatives commented on how kind staff were and this was evident in the way they dealt with residents. DS0000033522.V313916.R01.S.doc Version 5.2 Page 14 Relatives said they always felt welcome at the home and could visit any time. Some relatives were concerned about a lack of activities on the units. They felt the environment was not stimulating enough. One person said there was not even a magazine for residents to look at. Staff agreed there had been fewer activities during recent months because of staffing problems. The new manager is aware that this is an area that needs to be dealt with. Whenever they can staff spend time sitting and talking to residents either individually or in small groups. One person was disappointed that her relative had less access to the day centre since becoming a long-stay resident. The day centre can only accommodate a limited number of people at any one time and the arrangements for access to the day centre should be made clear at the time of admission. Bedrooms doors are kept locked during the day, this has been common practice for some time and came about to prevent people wandering into each other’s bedrooms. However one relative felt this made it difficult for visits to take place in private. If relatives want to visit in private they have to find the staff to get the key and then to return it. One visitor wanted to take her mother out and had to wait for staff to get the key so that she could get her mother’s coat and then find the staff member again to return the key. Many of the residents’ bedrooms have lots of their personal possessions but residents do not really benefit from this because they are only in their rooms when they are in bed. Some people may prefer to have their bedroom doors locked but it should not be routine practice. The menus are displayed and show that alternatives are available. Staff confirmed that alternatives are provided if residents do not like the main meal. Catering staff said they get information from staff on the units about residents’ needs and preferences. Residents have their meals on the individual units and sometimes staff sit and eat with them. I stayed on one unit while residents were having their lunch. The meal was relaxed and pleasant for residents. The tables were nicely set and condiments were put on the tables so that residents could help themselves. Residents who like to walk about were not brought to the table until their meal was ready and where necessary residents were gently encouraged to eat. The meal looked appetising and the residents clearly enjoyed it. Relatives were happy with the food and many residents have put on weight since moving in. Each unit has a small kitchen and drinks and snacks are DS0000033522.V313916.R01.S.doc Version 5.2 Page 15 available at any time. During the morning residents were offered a selection of fresh fruit and a visitor said this happened regularly. DS0000033522.V313916.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. There are detailed policies and procedures to guide staff in dealing with complaints and the protection of vulnerable adults. The manager is committed to creating an open and inclusive atmosphere that encourages people to share their views of the service. EVIDENCE: Some relatives were not aware of the complaints’ procedure but said they had no reason to complain. The Social Services department has a detailed complaints’ procedure and there is a central complaints’ officer who deals with complaints that cannot be resolved by the home. The manager understands that people may be reluctant to complain for a variety of reasons. She wants to make sure that people involved with the service are encouraged to make suggestions for improvement or raise concerns. A new notice giving people information about the complaints’ procedure has been prepared and will be made available in the home. The manager has introduced a system for recording complaints that shows the details of the complaint, the action taken, and the outcome. She has recorded two complaints since she took up her post. DS0000033522.V313916.R01.S.doc Version 5.2 Page 17 Approximately half of the staff have attended training on Adult Protection and training is planned for the remainder of the staff. Staff had a good understanding of abuse and were able to give examples of how peoples’ rights could be abused by poor care practices. They were aware of how to report any concerns they might have. DS0000033522.V313916.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, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Generally Holmewood is a pleasant and comfortable place for people to live. However, the problems with the hot water supply are putting the health, safety, and well being of residents and staff at risk. EVIDENCE: The layout of the home is good; the small units help to create a homely environment. A number of relatives said they really liked the design of the home. Generally the home is well maintained and the furnishing and décor are suitable for the residents’ needs. The home was clean. There was a major problem with the hot water supply, it was not entirely clear how long this had been going on for, but staff said it had got much worse over DS0000033522.V313916.R01.S.doc Version 5.2 Page 19 the past 2 months. There was very poor water pressure in some areas with only a trickle of water coming from the hot taps. In other parts of the home the hot water temperatures were well below the recommended temperature range, (38 – 43 degrees C). Staff said they did not know from one day to the next if there would be any hot water and where it would be. As a result staff were boiling kettles of water and carrying them to residents’ bedrooms to help them wash. This is not safe practice and puts both residents and staff at risk of scalding. Staff were unable to plan when residents could have baths because they could not be sure when hot water would be available. However to the credit of the staff the residents all looked clean and well groomed. The absence of a regular supply of hot water also increases the risk of cross infection because staff cannot always wash their hands properly. The manager said various plumbers had visited the home but none had been able to restore a regular supply of hot water to all parts of the home. The problem was discussed with one of the senior management team and an immediate requirement notice was issued. We were informed that immediate action would be taken to solve the problem. There were bars of soap in some of the shared bathrooms; the use of communal bars of soap is unhygienic and increases the risk of cross infection. Some of the bathrooms and toilets did not have soap dispensers and paper towels. DS0000033522.V313916.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, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The manager is dealing with the staffing problems that the home has experienced over the past few months and is putting the new staffing structure in place. This should ensure that there are always enough staff available to meet residents’ needs. The recruitment procedures followed by the home provide protection for residents. Staff are supported in developing the knowledge and skills they need to meet residents needs. EVIDENCE: There have been some problems with staffing over the past few months. Earlier this year the manager left and the deputy was moved to another service. The home has had unusually high levels of absence due to sickness. This combined with the vacancies put a lot of pressure on the existing staff team. This has had an affect on residents’ care, mainly in the area of social care, which has not been getting as much attention as it should. DS0000033522.V313916.R01.S.doc Version 5.2 Page 21 Some relatives said they were concerned that the home had seemed short of staff recently and said they felt the care was much better when the regular staff were on duty. The new manager has been in post since September 2006. She is confident that the staffing situation will improve. The interviews for the deputy manager post have taken place. The organisation is making changes to the staffing structure of all its residential services including Holmewood. When the new structure is in place the home will have a manager, a deputy manager, and 2 assistant managers. The assistant managers will each have responsibility for two units. The care assistants’ roles will be developed and senior care assistant posts will be introduced. Care staff said they were looking forward to the changes. Relatives clearly have a high regard for the staff; they described them as “friendly” “caring” “excellent” and “lovely”. I looked at three staff files; they showed that all the required pre-employment checks are completed before new staff start work in the home. Information provided showed that 50 of staff are qualified to NVQ level 2. This meets the recommendations of the National Minimum Standards. The home is well supported by the Social Services Workforce Development Unit, which offers a wide range of courses such as dementia care, health and safety, moving and handling and first aid. The home keeps detailed training records and these showed that the majority of staff have attended training on dementia care. The manager was working on the training plan for next year. This will include training on adult protection and medicines for those who have not yet attended or need to update their training. The manager is aware that staff need more training on the new system for care records. DS0000033522.V313916.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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The new manager has the relevant experience for the role and has a clear understanding of her responsibilities. The home needs to do some work on establishing systems for formal consultation with people who use the service. There are appropriate systems in place to make sure that residents’ financial interests are safeguarded. To safeguard the well being of residents and staff the organisation must reexamine the way in which it deals with serious maintenance issues. DS0000033522.V313916.R01.S.doc Version 5.2 Page 23 EVIDENCE: The new manager has been in post since September 2006. She has many years experience in the care sector, including experience as a manager. She is preparing her application for registration. This is her first position with Bradford Social Services, (BSS). A manager from another BSS home has been appointed as her mentor to help her get to know the organisations’ systems. This is good practice. Staff said they thought the new manager was very approachable. There are some systems in place for monitoring quality. Senior managers and managers from other services visit the home monthly and prepare reports. During these visits they look at various aspects of the service and talk to residents and staff. Residents meetings have not been held regularly, the new manager intends to hold monthly meetings for residents and their relatives. There have not been any staff meetings for a while, but one was planned for the week following the inspection. The new manager plans to hold staff meetings about every 3 months. It was not clear if any questionnaires had been issued however the manager had already identified this as an area to be addressed. There is no doubt that a lot of informal consultation takes place. However, a more formal approach is needed to make sure that everyone who uses the service is given an opportunity to express his or her views. The home has good systems for dealing with residents’ money. There are two systems in place. One deals with the money of residents receiving long-term care and the other deals with money held on behalf of residents receiving respite care. In both cases detailed records are available showing all transactions. The organisation has a separate savings account for money belonging to residents receiving long-term care. If residents accumulate large amounts of money it is deposited in this account on their behalf. It is a noninterest bearing account. The home confirmed that they had done the work recommended by the Fire Safety Officer. Information provided showed that, in general, the systems for dealing with repairs and maintenance work well. However, the health, safety and well being of residents and staff has been put at risk because the problems with the hot water supply have not been dealt with in a timely way. DS0000033522.V313916.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 1 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 DS0000033522.V313916.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4&5 Requirement The registered persons must provide the Commission with an updated version of the Statement of Purpose and Service User guide. The registered persons must make sure that the care plans set out in detail how residents’ personal, health and social care needs will be will be addressed. The registered persons must make sure that residents are given the opportunity to take part in social activities that reflect their needs, preferences, and abilities. The registered persons must make sure that there is a constant supply of hot water, maintained at the recommended temperature, to all parts of the home. The registered persons must make sure that suitable hand washing facilities for staff are provided in all communal toilets and bathrooms. Timescale for action 23/02/07 2 OP7 15 23/03/07 3 OP12 16 23/02/07 4 OP25 23 13/12/06 5 OP26 13 23/03/07 DS0000033522.V313916.R01.S.doc Version 5.2 Page 26 6 OP27 18 7 OP33 24 The registered persons must make sure that there are always enough staff available to meet residents’ needs. The registered persons must establish and maintain a system for evaluating the quality of the services provided. 23/02/07 23/03/07 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 Refer to Standard OP10 Good Practice Recommendations The home should review the practice of routinely locking all bedroom doors during the day. DS0000033522.V313916.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000033522.V313916.R01.S.doc Version 5.2 Page 28 - 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!