Inspection on 05/07/06 for Mary Chapman Court

This inspection was carried out on 5th July 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

Mary Chapman Court 24/10/08

Mary Chapman Court 28/06/07

Mary Chapman Court 18/08/05

Mary Chapman Court 01/04/05

Mary Chapman Court 09/11/04

Mary Chapman Court 20/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Mary Chapman Court Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD Lead Inspector Maggie Prettyman Unannounced Inspection 5th July 2006 10:00 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 Mary Chapman Court DS0000044397.V303435.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. Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mary Chapman Court Address Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD 01603 701188 01603 436848 ketkibpatel@hotmail.com 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) Alphacare Services (UK) Ltd Position Vacant Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to thirty-four (34) Older People, not falling into any other category, may be accommodated. 18th August 2005 Date of last inspection Brief Description of the Service: Purpose built in 1997, Mary Chapman Court is located in a residential area on the outskirts of Norwich in Thorpe St Andrew. The home can accommodate 34 older people in 28 single (26 with en-suite) and three double rooms (1 with en-suite). The accommodation is on the ground and first floors. The first floor can be accessed by passenger lift. The surrounding lawns and garden areas are well maintained and can be accessed by service users. There is ample parking space at the front and to the rear of the premises. The local GP practices, and other health professionals support the home. The range of fees charged is £240 - £450 per week Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current quality judgements for each outcome group. What the service does well: What has improved since the last inspection? A new acting manager is now in post. The service user guide has been updated and improved. Previous requirements and recommendations relating to medication have been implemented and a new dosette system of medication is in place. The new acting manager has made great effort to promote the homes’ whistle blowing procedures. Some refurbishment and redecoration has taken place. The new manager has implemented a system of appraisal and supervision, and has many plans for further improving standards in the home. Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 6 The organisation has started to share training opportunities between homes to provide an ongoing system of planned training. The organisation has also taken steps to speed up the process of CRB checking of prospective staff. What they could do better: 15 requirements and 14 recommendations are made in this report. Some are repeated from previous reports as the providers have not complied. The requirements can be summarised as follows; • • • • • • • • • • • • • • • Drugs requiring temperature control must be appropriately stored Staff found not to be competent in the administration of medicines must be removed from this duty Medicines with limited dispensing life must have their date of opening recorded A stimulating and varied programme of activities must be reinstated A competent cook must be recruited Adult protection and dementia care training must be provided for all staff Bathrooms must be kept free of clutter Commodes and toilets must be properly maintained, and not adapted in an unsafe way The home must review staffing levels to assess their adequacy in meeting service user needs The organisation must facilitate staff to gain NVQ qualification A consistent procedure for the recruitment and vetting of staff must be implemented. CRB checks must be in place for staff prior to employment A system of quality audit and feedback must be implemented by the home Secure facilities for service users to keep items of value must be offered. The new system of supervision must be maintained, with an annual appraisal completed in conjunction with the worker The good practice recommendations of the report are as follows; • • • • • • • The service user plan should be more detailed and include a life history of the service user with their agreement Service user records should be maintained in one format Notes from health professionals should be transferred to care plans and implemented The new cook should be encouraged to provide a wider variety of dishes and food types, particularly at teatime A record of complaints, comments and compliments should be kept and audited The home should continue with its programme of redecoration and refurbishment Equipment to label service user clothes should be freely available DS0000044397.V303435.R01.S.doc Version 5.2 Page 7 Mary Chapman Court • • • • • • • Staff shortages should not make designated staff unable to provide a consistent service The organisation should review its bank staff arrangements to improve flexibility of supply The new manager should apply for registration with the commission The manager should be offered professional supervision and support by the organisation An audit of accidents should be regularly undertaken A photo board of senior staff should be displayed and care worker uniforms simplified to denote their role All paint and flammable items should be removed from the upstairs storage cupboard 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. Mary Chapman Court DS0000044397.V303435.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 Mary Chapman Court DS0000044397.V303435.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, 2, 3, 5 and 6 The overall quality outcome for these standards is good. A new service user guide gives service users 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 their needs assessed. Prospective service users and their representatives have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users referred for intermediate care are helped to maximise their independence and return home. EVIDENCE: The acting manager has completed a revised Service User Guide, which she gives to prospective service users when she visits to do the needs assessment. Inspection of service user records demonstrated that contracts are in place for service users. Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 10 Evidence from service user files shows that a basic needs assessment, and if available, supplementary information from health and social services, is in place prior to the admission of any service user to the home. Service users and their relatives confirmed that they were able to visit prior to being admitted, and that a four-week trial period occurs before the stay is agreed to be long term. A service user is currently being offered rehabilitation to enable them to return to their own home after a period of illness. Mary Chapman Court DS0000044397.V303435.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 The overall quality outcome for these standards is adequate. A basic plan of care is in place for all service users. Service users health care needs are being met more effectively by the home, but some improvements in communication need to be made. The system of medication administration in the home has improved, but action needs to be taken immediately if staff fall short in their duties. Service users are treated with respect and their right to privacy is upheld. The home is working towards providing more palliative care. EVIDENCE: Basic service user plans are in place and evidence of review was seen. Plans could contain more detail and personal history and could have more input from service users. It is recommended that service user plans contain more detail and life history if agreed by the service user, and that service users could have more involvement in their construction and review. Additionally several different types of records are kept including a diary and handover book. It is recommended that one type of consistent record be Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 12 maintained for each service user to ensure continuity and consistency in records and service delivery. Prior to inspection, comments about a lack of consistency in health care delivery were received from health care professionals. During the inspection a visit by a continence advisor was hampered by staff shortages. A handover book completed by health care professionals contained notes that are not necessarily transferred to the care plan. It is recommended that a system be put in place to ensure that advice given during health professional visits is transferred to the care plan and implemented. Since the last inspection a new system of dosette boxes has been introduced to improve the medication procedures in the home. Inspection of records shows that medication is usually accurately administered and recorded, and all requirements and recommendations from the last pharmacy inspection have been implemented. Evidence was seen of a staff member continuing to have responsibility for administration of medication, despite shortfall in their practice being identified. It is required that all staff administering medication are competent to do so, and if found not to be for any reason, are removed from these duties. During the inspection eye drops were found in the drugs trolley and not stored in the fridge. Current temperatures mean that this may be inappropriate. It is required that drugs requiring temperature control are kept in the fridge if necessary. In addition some drops did not have the date of opening recorded on them. It is required that all medicines with limited dispensing time have the date of opening recorded on them. During the inspection staff were observed to treat service users with courtesy and respect. Feedback from service user questionnaires and discussions with service users and their families support this. Some service users have their own telephones in their rooms and post is given to them unopened. The pre inspection questionnaire demonstrates that in the past year most service users that have passed away have done so in hospital. The new acting manager proposes to implement palliative care training for staff to help more people to remain in the home for their final days. Mary Chapman Court DS0000044397.V303435.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 and 15 The overall quality outcome for these standards is adequate. The home does not currently have a consistent programme of activities. Service users maintain contact with their family and their friends if they wish. Service users are helped to exercise choice and control over their lives. The home is currently experiencing difficulties in providing a good quality and varied diet due to staffing difficulties. EVIDENCE: The post of activities co-ordinator is currently vacant, so no ongoing programme of activities is in place. Some activities are taking place such as film shows, trips to a local supermarket and café and the availability a room of reminiscence items. It is required that a stimulating and varied programme of activities is reinstated in the home as soon as possible. During the inspection numerous relatives and friends were observed to visit people in the home. Those spoken to confirmed that they are made welcome and visits are not limited in any way. Religious observance is available every fortnight. Service users are consulted about their choice from the menu twice daily. Those spoken to confirmed that they could stay in their rooms or sit in lounges as they wish, and that meals can be taken in the location of their choice. One Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 14 service user manages their own money and lives a largely independent lifestyle. Rooms contain many personal possessions and are individualised. The home would benefit from having photographs of senior staff displayed, and simple uniforms that identify the role of the worker. It is recommended that a clear photo board of senior staff is displayed and that a simplified and unified system of uniform is used. On the day of inspection the newly appointed cook had left due to being asked to improve the standards of meals provided as the quality of food recently has been poor. The post was re advertised immediately on the day, and alternative temporary arrangements made. It is required that a competent cook is employed in the home as a matter of urgency. Menus provided lacked variety in the afternoons and evenings. It is recommended that the new cook is encouraged to provide a wider variety of dishes and food types, particularly at teatime. Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The overall quality outcome for these standards is adequate. Service user complaints are acted upon, but no audit of complaints and compliments takes place. The home has taken appropriate action following an allegation of abuse, but further staff training is required. EVIDENCE: Evidence of appropriate action following complaints was seen. It is recommended that the home records minor complaints as well as comments and suggestions about the service to provide a wider range of information for the home to audit its practice. The new acting manager has provided good information about whistle blowing which has been placed around the home as well as in the new service user guide. A recent allegation was appropriately reported and dealt with. An appropriate POVA referral has taken place. Staff training in Adult Protection and working with behaviour that challenges is not in place. The new acting manager is currently working to deliver a suitable training programme in these subjects. It is required that appropriate Adult Protection and Dementia Care training takes place. Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 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, 21 and 26 The overall outcome for these standards is good. Service users live in an environment, which is safe and fairly well maintained. Service users have access to safe and comfortable indoor and outdoor communal facilities. Some bathing areas could be tidied. Despite staffing shortages, the home is clean, pleasant and hygienic. EVIDENCE: A tour of the premises showed them to be tidy and fairly well maintained. Some redecoration and re carpeting is underway. It is recommended that the home continue with the programme of redecoration and refurbishment recently commenced. Records of servicing and compliance were seen. The lounges, dining areas and gardens are attractive and comfortable. A reminiscence room is also available. Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 17 Some bathrooms were found to contain unnecessary equipment Unsuitable unfixed temporary seats were found on some toilets, and a broken commode was found in a service users’ room. It is required that all bathrooms are kept clutter free and comfortable. It is also required that commodes and toilets are properly maintained, and that any equipment used is fit for its purpose. On the day of inspection the home was suffering staffing shortages. The home was reasonably clean, and good standards of hygiene were observed. The laundry contains appropriate and well-maintained equipment. The laundress confirmed that laundry is appropriately sorted, with foul linen kept separately. Some issues have occurred due to items not being labelled and staff shortages meaning that ironing and laundering of special items has been delayed. It is recommended that more equipment to label service users clothes be provided. It is also recommended that staff shortage does not mean that designated staff are unable to provide a consistent service. Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 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 and 30 The overall quality outcome for these standards is poor. The home needs to review its staffing levels and availability of relief staff. The home has not yet met its NVQ targets. The home lacks a consistent recruitment policy and procedure. EVIDENCE: Staff working in the home were observed by the inspector to be cheerful and hard working. On the day of inspection the home was suffering severe staff shortages. There were some vacancies as well as sickness absence and the departure of the cook that morning. It is required that the home does a review of staffing and service user needs to assess the adequacy of its staffing levels. It is also recommended that the organisation look at its bank staff arrangements to ensure that a viable source of replacement staff is available to cover short notice absence. The home is not on target for its NVQ training requirements. It is required that the organisation facilitates staff to attend NVQ training courses. Examination of staff files showed that vetting of staff is inconsistent, and that CRB checks are not always in place prior to staff commencing work. The organisation has begun to address these issues. It is required that a consistent procedure for the recruitment and vetting of staff is written and implemented. It is also required that CRB clearance is gained for staff prior to their employment in the home. Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 19 Training needs analysis for the home has been completed in respect of statutory training. The organisation is beginning to share training resources amongst its homes. Evidence of induction training was seen during the inspection. Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 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, 35, 36 and 38 The overall quality outcome for these standards is good. The acting manager of the home is discharging her duties well. Quality assurance audits are planned. Service users financial interests are safeguarded. The health, safety and welfare of service users are protected. EVIDENCE: The recently appointed acting manager of the home is a committed, caring, experienced and well-trained person. Discussion with residents and staff demonstrate that she has their confidence and support. It is recommended that she apply for registration by the commission as a matter of priority. The acting manager plans to conduct a quality survey for service users in the near future. A residents meeting has taken place, with suggestions Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 21 implemented. The minutes of this meeting have yet to be distributed. A newsletter is planned. Further quality audits need to take place. It is required that a system of quality audit and feedback be implemented by the home. Money held on behalf of service users was randomly checked and found to be accurate. Secure storage facilities are needed in some service users rooms. It is recommended that secure storage facilities are offered to those service users that require them. The acting manager has commenced a system of appraisal and supervision for staff. It is required that this system of supervision is maintained and that a detailed annual appraisal is completed in conjunction with workers. It is recommended that the acting manager be offered suitable professional support and supervision. Suitable mandatory health and safety training is in place. Equipment was observed to be used appropriately. Accidents are recorded, but no detailed audit currently takes place. It is recommended that a detailed audit of accidents takes place to identify service users or areas of practice that are at risk. Due to misunderstanding, some incidents had not been notified to the commission. The manager was advised of her responsibilities and will notify the commission as a matter of course in future. Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 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 3 3 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 2 X X X X 3 STAFFING Standard No Score 27 2 28 1 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 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 2 Standard OP9 OP9 Regulation 13 13 Requirement Any medicines requiring temperature control must be appropriately stored. All medication with limited storage life must have its date of opening recorded on the container. All staff dispensing medicine must be competent to so, and if not removed from these duties. A stimulating programme of social and cultural activities must be provided by the home. A competent cook must be permanently employed by the home as a matter of urgency. Adult protection and dementia care training must be given to all staff. Bathrooms are to be kept free of clutter and items that should be stored elsewhere. Toilets and commodes must be properly maintained, and unsafe adaptations must not be made. The home must review its staffing levels in the light of assessed needs of service users. Repeated Requirement. DS0000044397.V303435.R01.S.doc Timescale for action 31/07/06 31/07/06 3 4 5 6 7 8 9 OP9 OP12 OP15 OP18 OP21 OP21 OP27 13 16 16 13 23 23 18 31/07/06 31/08/06 31/08/06 30/09/06 31/07/06 31/07/06 31/08/06 Mary Chapman Court Version 5.2 Page 24 10 11 OP28 OP29 18 19, Schedule 2 19, Schedule 2 12 OP29 13 14 15 OP33 OP35 OP36 24 16 18 The organisation must facilitate staff to gain NVQ qualification. Repeated Requirement. The home must develop and implement a consistent procedure for the recruitment and vetting of staff. All staff must have satisfactory CRB clearance prior to employment by the home. Unless they are under constant supervision in line with Department of Health POVA1 guidelines. A system of quality audit, review and feedback must be implemented by the home. Secure facilities must be provided for service users wishing to hold valuables. The system of supervision and annual appraisal must be maintained. Repeated Requirement. 31/10/06 31/08/06 31/07/06 30/11/06 31/08/06 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP7 OP7 OP8 OP15 OP16 OP19 Good Practice Recommendations The service user plan should be more detailed and contain details of service users life histories if they agree. Service user records should be maintained in one, easily read format. Health professional notes should be transferred to service user plans and implemented. The new cook should be encouraged to provide a wider variety of dishes and food types, especially at suppertime. A record of minor complaints, comments, suggestions and compliments should be kept to enable audit of services provided. The home should continue with its programme of DS0000044397.V303435.R01.S.doc Version 5.2 Page 25 Mary Chapman Court 7 8 9 10 11 12 13 14 OP26 OP26 OP27 OP31 OP36 OP38 OP14 OP38 redecoration and refurbishment. Adequate equipment to label service users clothes should be freely available. The consistency of services, such as laundry, should not be impaired by staff shortages. The organisation should review its bank staffing arrangements to ensure a viable source of replacement staff is available at short notice. The acting manager should apply for registration with the commission. The acting manager should be offered suitable professional supervision and support by the organisation. A regular audit of accidents should be undertaken to identify service users or areas of practice or service delivery at risk. A photo board of senior staff should be displayed and uniforms simplified and unified to denote workers roles. All paint should be removed from the upstairs storage cupboard Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Mary Chapman Court DS0000044397.V303435.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!