CARE HOMES FOR OLDER PEOPLE
James Terry Court 51 Warham Road South Croydon Surrey CR2 6LH Lead Inspector
Lee Willis Unannounced Inspection 13th February 2006 12:30 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 James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service James Terry Court Address 51 Warham Road South Croydon Surrey CR2 6LH 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) 020 8688 1745 020 8688 0587 www.rmbi.org.uk Royal Masonic Benevolent Institution Mrs Diane Margaret Collins Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Total number of exclusively nursing beds = 13 Total number of dually registered beds = 7 Total number of exclusively residential beds = 38 Date of last inspection 3rd August 2005 Brief Description of the Service: James Terry Court is owned, managed and staffed by the Royal Masonic Benevolent Institute (RMBI). This residential care and nursing home provides accommodation and care for up to 58 older Freemasons and the dependent females of Freemasons, of which 38 of these places are residential, 13 are reserved for nursing only, and 7 are dual registered. Mrs Diane Collins has been in operational day-to-day control of the home since January 2004 and has recently undergone a ‘fit’ person interview with the CSCI to register as the homes permanent manager. There have been no significant environmental changes made to the home since it was last inspected, although the CSCI is aware that plans to redevelop the entire site are still being considered by the Local Council. This vast building is set back from a main road in a suburban area of South Croydon and is within easy walking distance of a wide variety of local shops, restaurants, pubs and cafes. The home is also on a main line bus route and within a few miles of a local train station with good links to central London and the surrounding areas. The building can be divided into distinct halves, comprising of a modern wing specifically designated for nursing care only and a much older wing primarily used for residential care. Most of the service users are provided with their own single occupancy bedrooms, 54 in total, although there are also 2 double rooms for couples who wish to share. Communal space comprises of a large open plan dining room on the lower ground floor, which also has a small conservatory attached; and a number of different sized lounges located throughout the home, which includes an activities room and library. There are sufficiently numbers of toilet and bathing facilities located throughout the building near service users bedrooms and communal areas. The building itself is surrounded by a pleasant secluded back garden onto which many of the bedrooms, including the majority of the communal areas, overlook. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 12.30 on the morning of Monday the 13th February 2006. It took four hours to complete. Since the homes last inspection the Commission has received two more comment cards in respect of this service, one of which was completed by a service users friend and the other by a relative. The majority of this inspection was spent talking to the homes recently registered manager; half a dozen members of staff, including several care workers, the homes activities coordinator, and the cook; four members of one service users immediate family, who were visiting at the time; and a dozen or so service users, of whom three were spoken with at length. The remainder of this inspection was spent examining the homes records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months. What the service does well:
Overall, James Terry Court is a good quality service with significantly more strengths than weaknesses. The home is consistently managed and generally delivers ‘positive’ outcomes for the people who live there. The three service users spoken with at length, along with the visiting relatives of another, all said that overall they were very satisfied with the standard of care provided at the home and were particularly impressed with the attitude of most of the staff team. The friends of one service user wrote on a comment card “ James Terry Court is in our opinion an excellent home of very high standards. All the staff are always most polite and helpful. We are always made welcome and have never had any cause for complaint.” All the staff met during the course of this unannounced inspection, including carer workers, nurses, catering staff and the activities coordinator, were not only extremely courteous and welcoming, but were all observed interacting with the service users in a very kind and respectful manner. One service users relative wrote on a comment card “ my mother receives good nursing care and has made remarkable advances since being admitted.” The home also continues to experience relatively low levels of staff turnover, thus ensuring the service users receive continuity of care from an experienced group of social/health care professionals who are familiar with their unique needs, preferences, and strengths. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 6 Finally, the home has a very open culture and works in close partnership with the service users and their families, as well as professional bodies, including the CSCI, Croydon Social Services, and the London Health Protection Agency. E.g. By notifying all the relevant agencies without delay about two significant incidents that recently occurred in the home, staff were able to act swiftly to resolve both these matters, for which they are commended (For further details see the main body of this report). What has improved since the last inspection?
The home has managed to meet all the requirements identified in its last inspection report within the prescribed timescales for action. Important areas of practice that have improved since then, include: The homes new index system, which makes it far easier for people to access information held in care plans. These documents are now divided up into distinct sections, which are numbered for ease of referencing purposes. The introduction of a more user ‘friendly’ concerns and suggestions book, which is to be used in conjunction with the homes formal complaints log, will enable service users and their representatives to have even more opportunities to express their views about the service provided at James Terry Court and its day-to-day operation. Finally, sufficient numbers of the homes current staff team have now attended suitable courses in the appropriate use of moving and handling techniques and controlling infection. The RMBI has also ensured that at least 50 of its current care staff team have now achieved a National Vocational Qualification in care level 2 or above, in line with Government training targets for care workers. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 7 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. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 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 James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 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): None of the Standards No’s# 1 to 6 were inspected on this occasion as key Standard No#3 has already been inspected once in the past 12 months, and key Standard No#6 remains non-applicable, as the service does not provide any intermediate care. EVIDENCE: James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 The home has suitable arrangements in place to ensure service users individual personal, social and health care needs are planned for and met. EVIDENCE: The three care plans sampled at random had all been reviewed on a monthly basis and updated accordingly to reflect any changes in these particular service users personal, social and health care needs. Since the homes last inspection the existing care plan format has been improved and an excellent index system introduced, which makes it far easy to access the information contained in these documents. All the plans examined contained a lot of detailed information about each individual service users past life, medical history, social interests, food preferences and personal goals. The manager said she was currently in the process of taking new photographs of each of the service users and these would be included on their care plans within the next few months. None of the service users currently residing at the home have any pressure sores and all the care plans inspected at random contained up to date tissue viability (waterlow) assessments identify how at risk each service user was of
James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 11 developing them. The homes accident book revealed that there had been three significant accidents involving service users since August 2005, which had all resulted in unplanned admissions to accident and emergency. All three accidents pertained to falls, which had occurred both inside and outside the home. Records revealed that staff on duty at the time had effectively dealt with all these significant incidents and all the relevant agencies had been notified without delay, including the CSCI and various care managers. Similarly, following a recent outbreak of an infectious disease at the home, all the relevant health and social care authorities, including the Local Health Protection Agency, were notified and advice sought to ensure the home was able to take appropriate steps to prevent its spread. The containment strategy employed by the home proofed extremely successfully and the staff team are commended for the efficient manner in which they dealt with this health crisis. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The home ensures service users have every opportunity to pursue their social, religious and recreational interests, both at home and in the wider community. These opportunities are well managed, ‘age’ appropriate, and provide the service users with daily variety and stimulation. Service users are also offered a wide variety of nutritionally well-balanced and appealing food ensuring their dietary needs and preferences are well catered for. EVIDENCE: The three service users met during lunch said they all found the lifestyle they experienced in the home matched their expectations. This group of individuals, went onto say they were always notified about all the forthcoming social and recreational events to be held at the home, but as a rule tended to prefer their own and each others company and would spent most of their time either relaxing together in the conservatory or in the privacy of their bedrooms. Several other service users spoken with after lunch said they were very impressed with the new activities coordinator and particularly enjoyed the regular art sessions and day trips she arranged. That afternoon several service users said a film was going to be shown in the main lounge. The activities coordinator said over the past few months a number of entertainers had performed at the home, including a magician, a local choir, and a classical orchestra.
James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 13 Furthermore, a group of relatives met during this inspection all said they were always invited to attend the various social events arranged by the home, which included an annual summer fete and a fire works display every bonfire night. Each of the service users care plans sampled at random contained details about each individuals spiritual needs and the manager confirmed that a Priest visited the home on a weekly basis to hold Communion for the homes only practising Roman Catholic. The aforementioned relatives spoken with at length also said they were very satisfied with the overall standard of care their loved one received at the home and they were particularly impressed with the homes extremely open and flexible visitors policy, which allowed them to almost come and go as they pleased. It was evident from the comments made by this group of relatives and the way the staff on duty at the time interacted with them that good working relationships had built up between them over some considerable time. One of these relatives went onto say it was customary for staff to offer service users guests the chance to stay for a meal if they wished, which had proved very popular on Sundays. As recommended in the homes previous inspection report a lot of information about how service users and their relatives can contact external advocacy groups was conspicuously displayed on a notice board in the entrance hall. The overwhelming response of all the service users spoken with about the quality of meals served was extremely positive. All three of the service users joined for lunch said the meals were always tasty and well presented. One service user remarked that the quality of the food at the home “was probably the thing they enjoyed most about living at James Terry Court”. The meals advertised on the published menu for the day matched the meals being served up by the kitchen staff over lunch. On the day service users had a choice of chicken salad, spinach and salmon pie, and roast pork. The fish pie looked particularly appetising and nutritionally well balanced. It was positively noted that all the potatoes and vegetables that accompanied these main meals were served separately as side dishes, which enabled all the diners to help themselves. The atmosphere in the dining room over lunch felt very relaxed and pleasant. It was also pleasing to note that the chef went around to all the diners at the end of their meal to ask them in person what they had thought of their food and make a note of peoples responses. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The arrangements the home has in place for dealing with complaints ensures service users and their representatives concerns will always be taken seriously and acted upon. The homes vulnerable adult protection and abuse prevention measures are also suitably robust to ensure the service users are, so far as reasonable practicable, protected from avoidable harm. EVIDENCE: Several service users and the relatives of another met during the course of this inspection all agreed that on the whole staff were very approachable and always took any concerns they may seriously. The homes complaints log revealed that no formal complaints had been made about homes operation since August 2006, although the homes new comments book, which was being used to record more informal concerns raised by service users and their representatives contained a dozen or new entries since its introduction in August 2006. This record showed the home had followed up all of the issues brought to the homes attention and where applicable, had taken action to successfully resolved them to the complainant’s satisfaction. The Commission considers the new concerns book to be a welcome addition to the homes record keeping and will enable the home to ascertain service users and their representatives views more effectively. In the past six months the home has received one allegation of abuse, which was disclosed by a service user who accused an unnamed member of staff of verbally abusing them. In accordance with the Local Authorities vulnerable adult protection protocols the home passed on these concerns without delay to
James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 15 all the relevant agencies, including, Croydon Social Services and the CSCI. All the professionals who attended the subsequent multi-agency strategy meeting, which was convened by the Local Authority to look into this matter, concluded that there was insufficient evidence to substantiate the allegation. The homes management are commended for the open and prompt manner in which they dealt with this issue, and in particular for notifying all the relevant authorities as soon as was reasonably practicable to do so. It was positively noted that well over half the care staff currently working at James Terry Court have now attended a ‘suitable’ training course in recognising, preventing and reporting elder abuse, which includes a video and a written exam. The manager said a date has already been booked for the rest of her staff team to receive this training by the end of February 2006. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22 & 25 The overall impression when visiting this home is that the service users live in an environment, which despite its vast size, remains safe, comfortable and hygienically clean. EVIDENCE: As mentioned in previous inspections reports, although the home remains suitable for its purpose, the manager and many of the service users met all agreed that the vast size and layout of the building does not lend itself particularly well to the concepts of ‘warmth’ and ‘homeliness’. Nonetheless, the manager is confident that draft plans to rebuild the home on the same site, which have recently been resubmitted to the Local Council, will be approved this time. The manager has amended the homes smoking policy to reflect the service users views on the matter following a recent vote. The policy now clearly states that service users who choose to smoke may do so in the new conservatory.
James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 17 At 15.30 a call bell in one of the communal lounges in the nursing wing was activated. It was positively noted that a qualified member of staff arrived on the scene within three minutes of the alarm being sounded. The manager said the home has a specialist device that records the exact time any call bell is turned on or off, and therefore she is able to closely monitor how effective staff are at responding to call bells. Having tested the temperature of hot water emanating from a tap attached to a bath in the nursing wing it was found to be a safe 42 degrees Celsius at 15.05. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 18 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 Overall, the home ensures that sufficient numbers of suitably competent staff are on duty at all times to meet the health and welfare needs of the service users. EVIDENCE: James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 19 During a brief tour of the premises there appeared to be sufficient numbers of staff on duty to meet the service users personal, social and health care needs. On arrival eight care workers, a shift leader and a registered nurse, the manager, an activities coordinator, and sufficient numbers of kitchen and domestic staff were all on duty. The relatives of one service user met during the course of this inspection confirmed that despite the vastness of the building, which meant staff were not always visible, they felt confident that sufficient numbers of suitably competent staff were always on duty and would generally be on hand if called. It was positively noted that in accordance with National Minimum training targets for care workers just over half the homes current staff team (cares) have now achieved their National Vocational Qualification in care level 2 or above, and a further five members are currently enrolled on a suitable NVQ course. The home continues to experience relatively low levels of staff turnover and consequently has only needed to recruit two new members of staff in the past six months. The files for both these members of staff were examined in some depth and found to contain the vast majority of information required by the Care Homes Regulations (2001), including: completed job applications; proof of identity; two written references; and Criminal Record Bureau and Protection of Vulnerable Adults checks. However, it was concerning to note that both these new members of staff had been allowed to commence working at the home before their full Criminal Records Bureau checks had been processed. The home is reminded that although persons employed as “care workers” may commence working at the home on just a POVA First check, the CSCI does not consider it to be good practice as this should only be allowed in exceptional or urgent circumstances where immediate replacement of staff is imperative. Furthermore, if a new member of staff is employed on just a POVA First, the home must obtain all the other documents specified in Schedule 2 of the Care Homes Regulations (2001), ensure the individual has at least applied for their full CRB and that they never work unsupervised with service users while their CRB is still being processed. It was positively noted that all the training shortfalls identified in the homes previous inspection report have either been addressed or arrangements made for staff to receive ‘suitable’ training in these core areas of practice, which included: moving and handling, and infection control courses. Furthermore, a detailed matrix of all the training undertaken by staff has also been compiled by the deputy manager, which not only identifies all the staffs’ current qualifications, but more importantly there training needs. The manager said she finds the matrix extremely useful and will keep it under constant review to ensure it accurately reflects her current staff’s team’s qualifications. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 20 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, 36 & 38 Overall, the health and safety arrangements the home has in place appear to be sufficiently robust to ensure the service users, their guests and staff are all protected from avoidable harm. However, the homes arrangements for ascertaining the views of service users and their representatives, although effective, the results of any quality assurance surveys undertaken by RMBI still need to be published. Without these results, service users, their representatives, and the Commission will be unable to measure how successful the home has been in achieving its stated aims and objectives. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 21 EVIDENCE: The homes manager, Diane Collins, has been in operational day-to-day control of James Terry Court for just over two years and has recently successfully undergone a ‘fit’ person interview with the CSCI to become the homes registered manager. The manager said a number of anonymous satisfaction questionnaires had been given out to service users and their relatives in November 2005 and completed forms were still being collected by the RMBI. The manager is confident that the results of these surveys will be published as soon as they are ready and made available to all the relevant stakeholders, including service users, their relatives, care managers, and the CSCI. Progress on this matter will be assessed at the homes next inspection. It was positively noted that all the staff spoken with at length during the course of this inspection said they had all received formal supervision sessions with their line manager in the past two months, as well as an appraisal of their overall performance each year. Staff files sampled at random confirmed that the homes senior staff continue to maintain appropriate records of these formal supervision sessions with their colleagues. The home has undertaken a comprehensive fire safety risk assessment of the building, which is kept under constant review. Furthermore, fire records revealed that the homes fire alarm system continues to be tested on a weekly basis and emergency lighting checks carried out every month. As required in the homes previous inspection report the faulty automatic release mechanism attached to a fire door in the kitchen was repaired within the prescribed timescale for action. The homes maintenance man was able produce up to date Certificates of worthiness on request as proof that ‘suitably’ qualified engineers’ had tested all the homes gas installations and portable electrical appliances in the past twelve months. Furthermore, Certificates of worthiness were also available on request to show ‘suitably’ qualified professionals continue to test the homes passenger lift on a monthly basis and mobile hoists (all six) on a bi-annual basis. The temperature of the water used in the homes tank is also tested for legionella on a monthly basis. James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 22 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X X 3 X STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 3 X 3 James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 23 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 OP29 Regulation 13 & 19, S. 2.5 2.7 Requirement Only in “exceptional” circumstances where immediate replacement of staff is imperative may care staff commence working at the home on a POVA First check whilst waiting for their full Criminal Records Bureau Disclosure to be processed. The results of any service user and/or major stakeholder holder surveys/questionnaires undertaken by the service providers must be published as part of an effective quality assurance system. Timescale for action 01/03/06 2. OP33 12(3) & 24(2) 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 James Terry Court DS0000019030.V269178.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!
