Inspection on 15/12/05 for Min-Y-Don

This inspection was carried out on 15th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Min-Y-Don 07/05/08

Min-Y-Don 21/05/07

Min-Y-Don 16/10/05

Min-Y-Don 21/07/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Min-Y-Don Min-y-don 24 Clifton Road Tettenhall Wolverhampton West Midlands WV6 9AP Lead Inspector Bhag Jassal Unannounced Inspection 15/12/05 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 Min-Y-Don DS0000064532.V272963.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. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Min-Y-Don Address Min-y-don 24 Clifton Road Tettenhall Wolverhampton West Midlands WV6 9AP 01902 77 49 50 01902 774 953 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) West Midlands Residential Care Homes Ltd Mr Scott Taylor Care Home 26 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (26) of places Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered as a care home for older people subject to the provider meeting the Conditions of Registration in Appendix 1 dated 17/6/05. The home is registered for a maximum number of Twenty-Six (26) Service Users, Older People of which Nine (9) may be Older People with mild dementia. 21st July 2005 Date of last inspection Brief Description of the Service: The home is a large detached, Victorian property set in its own attractive grounds at the end of a private drive. A purpose-built extension has been added to the home. The home, which provides accommodation for 26 service users, is within walking distance of Tettenhall village where there is a post office, shops and a variety of other amenities. There are three double bedrooms, and 20 single bedrooms, three bathrooms, one shower, eight WCs, three lounge/dining rooms, a conservatory, laundry, kitchen, staff room and a managers office. There is a large car park and garden. Min-Y-Don DS0000064532.V272963.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 started at 9.00 am and lasted 7 hours and 10 minutes. 22 places were occupied and four remain vacant. The inspection included discussions with the Registered Manager, service users, the staff and relatives/friends. The daily routines were observed and service users and staff records, policies and procedures were examined. Inspection of premises both inside and outside and facilities were also undertaken. The ownership of Min-y-Don has changed in June 2005, and the new Registered Providers are the West Midlands Residential Care Homes Ltd. Mr Hari Balasubramaniam is the Registered Individual on behalf of the company. At the point of the last inspection conducted on 21 July 2005, there were several requirements to be addressed by the new Registered Providers by the end of August 2005. It was noted that the home has implemented all of these issues with the exception of one outstanding matter relating to the forecourt car park and entrance area. What the service does well: Min-y- Don is registered for 26 older people, of which 9 older people can have Dementia. The home makes every effort to provide individuals with a good standard of care to meet the assessed needs following a care plan. The home has a good key worker and staff supervision system in place. The home communicates well with the families/friends and representatives of the service users. The visitors’ book indicated a lot of activity. The service users spoken with said that they are happy and content with living in a homely and caring place. Service users were in the lounges engaging in their daily activities and they further commented that they were comfortable and satisfied with the care provided. The atmosphere within the home was observed to be relaxed, comfortable and friendly. The friendly rapport was also observed between service users and staff. Meals are varied, well balanced and presented to meet each individual’s choices, preferences and requirements. The home provides a good standard of accommodation, which is being maintained, is safe, secure and of a good standard. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The home has made good progress in implementing the requirements from the last inspection. The home must continue to improve further the quality of daily care recordings. The Registered Provider must ensure that those members of staff, who as yet not received training in safe working practice topics, must do so as a matter of priority. This training would enable them to improve further their care practices and professionalism. The Registered Manager must take swift action to fully implement its Annual Quality Assurance development plan. There are three requirements relating to the home’s environment, which must be addressed in order to have a safe and comfortable environment for service users, the staff and relatives/friends. Overall, the home has made good progress in complying with the requirements arising from the previous inspection report. It is also acknowledged that the Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 7 improvements being made to care practices and the home’s environment by the staff, Registered Manager, and the Registered Provider. 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. Min-Y-Don DS0000064532.V272963.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 Min-Y-Don DS0000064532.V272963.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): 3, 4 and 6 The home has a comprehensive needs assessment procedure providing an effective assessment, suitability, evaluation and its ability to meet the assessed care needs of both privately funded and those placed by the Local Authorities. EVIDENCE: A sample of three service users’ care plans and files were thoroughly examined at the inspection. All contained evidence that the service users receive the benefit of a comprehensive assessment prior to admission. The Registered Manager stated that he carry out assessments on both self-funded service users and those placed by the Local Authorities. The assessment details are documented on the service users’ care plans. Care plans are drawn up by the senior staff with the assistance from the service users and their relatives and where appropriate other professionals. The home has a good admissions procedure, which is made available to all prospective service users and their relatives and/or representatives. The service users and/or their relatives can visit the care home prior to admission. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 10 If they indicate that the care home is able to meet the needs of the prospective service users, then the home formally confirms in writing whether or not it can meet the assessed needs of the prospective service users. Once this is agreed between all the parties concerned, then the placements take place on a 28 days trial period. The home does not offer an intermediate care service. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 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, and 9 The staff within the home are aware and sensitive to the needs of each and all service users and meet their needs in a professional manner. There is clear and consistent care planning system in place, which provides the information the staff requires to meet the service users’ health and care needs. EVIDENCE: It was evidenced that all service users undergo a comprehensive assessment of their needs prior to admission to the care home. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plans and monthly reviews are implemented. Three service users’ care plans were examined in detail and it was noted that the short-term and long-term goals and appropriate interventions required to put them into action to meet the individual service user’s needs are identified. It was also evidenced that the care plans are being reviewed on a monthly basis. The daily care (day and night) recording formats were also examined and it was noted that the quality and detail of recording has steadily improved. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 12 The Registered Manager stated that the staff would be closely supervised and supported to make further improvements in daily care (both day and night) recordings. It was evidenced that the home ensures that the detailed nutritional screening is undertaken, including weight gain and loss records are maintained and appropriate action is taken if required. The home also maintains records of all health checks. The case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users health is closely monitored and appropriate medical care services are sought as and when required. The Inspector spoke to ten service users, who were able to have meaningful conversation. Generally the service users appeared to be content, comfortable and happy. Two service users’ relatives were also spoken to and they were satisfied with the care being provided by the home. It was evidenced from the staff training records updated in December 2005 and discussion with the Registered Manager that 17 carers have received their training in safe handling of medication. However, it is the Home’s policy that only the senior members of staff would be responsible for safe handling of, and administration of medication to service users. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 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, 14 and 15 Min-y-Don care home provides a good standard of care and promotes individual lifestyles for the service users in residence. The service users are positively helped to exercise choice and control over their lives as far as practicable and safe to do so. Meals at Min-y-Don are of a good homely type offering both choice and variety and catering for special needs. EVIDENCE: It was evidenced that the home provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to – social and leisure activities and cultural interests. It was also noted that the home organise entertainment delivered by external entertainers. The records of activities enjoyed by the service users are being appropriately maintained. The Registered Manager stated that the staff would be asked to be a little more pro-active in organising activities, both indoor and outdoor for the service users. The Registered Manager stated that the activities in the “New Wing” Unit for the service users with dementia care needs would be carefully planned, which would actually meet their particular needs and well-being. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 14 The Registered Manager stated that the service users are positively assisted and helped to exercise choice and control over their lives. A close liaison is maintained with the relatives and representatives, where the service users are not able to make certain decisions. The service users and their relatives are informed of the availability of the Advocacy Service based at the local Age Concern office. A poster about the Advocacy Service is displayed on the Notice Board in the entrance hall. It was evidenced that the home provided a varied, wholesome and nutritious diet. The meals provided during lunchtime on the day of inspection were well received by the service users. It was observed that those service users, who needed assistance in feeding, members of staff were available to assist those service users. The Registered Manager stated that the menu is changed on a regular basis and in consultation with the service users. Several service users told the Inspector that the food was nice, tasty and well prepared. The Kitchen is well equipped and kept clean and tidy. The catering staff are well trained in food safety and hygiene matters. However, the staff stated that the existing dishwasher in the kitchen is very inefficient and ineffective in cleaning the dishes, crockery and cutlery. The Registered Provider must ensure that a suitable dishwasher in the kitchen is provided as a matter of priority. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 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, 17 and 18 Concerns and complaints are dealt with promptly and professionally. The service users’ legal rights are promoted and protected. The service users are protected from abuse by the home’s policies and procedures. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has a good Complaints Procedure, which is referred to for information in the Service Users’ Guide. There is a satisfactory system of recording complaints and concerns. It was noted that there were only two complaints directed to the Commission for Social Care Inspection (CSCI) within the last 12 months. All the issues arising from these two complaints were addressed immediately and appropriately by the home. The service users are able to raise any concern or complaint about the services and facilities provided by the home. The Registered Manager stated that the home has provided a “suggestion box” in the main entrance hall for service users, members of staff and visitors to the home to use to help improve the quality of care and services at Min-y-Don. The Registered Manager stated as far as possible, the service users’ legal rights are promoted and protected appropriately. Where the service users are not able to make certain decisions, then their relatives and/or representatives are requested to assist, and where appropriate, the local Advocacy Service is also requested to help. The service users are positively assisted to take part in elections and they use their voting rights. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 16 The home has a good policy and procedure in place with regard to protection of service users from all forms of abuse. The Registered Manager stated that the staff have been made aware of the adult abuse and protection issues through induction training and supervision arrangements. It was also evidenced from the staff training records that all members of staff have received training in adult abuse and protection issues. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 and 26 The general standard of the environment is good providing service users with a comfortable place to live. The standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. However, the forecourt car park is tarmaced and potholes need to be appropriately repaired for the safe use of service users and other visitors to the home. The carpet in the main entrance doorway is desperately in need of replacing, the carpets in the hallway and corridors, and along the corridors in the “New Wing” Unit must be thoroughly and professionally cleaned. EVIDENCE: The home offers a comfortable and well-maintained environment to all service users. The home has ample communal space – three lounges/dining areas and a conservatory. The home has a rolling programme of redecoration to maintain good standard. The gardens and patio areas are also well maintained. The Registered Providers have provided new floor covering in the kitchen, food stores and staff WC. The damaged ceiling in the main lounge has been repainted and bedrooms 3 and 7 have also been redecorated. A suitable Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 18 ramp access has been provided from the “new wing” unit corridor to the court yard, patio and garden areas for the safe use by the service users. The Registered Manager stated that the home is in compliance with the West Midlands Fire Service and the Wolverhampton City Council’s Environmental Health Department requirements. Relevant documentation was seen, which appeared to be in order. There is a reasonable standard of furniture and fittings provided in the service users’ bedrooms. It was noted that many bedrooms have been “personalised” by the service users. However, the Registered Provider must provide suitable tables to sit at in four bedrooms; and replace fused light bulbs in several bedrooms. A new carpet in bedroom 5 must be fitted appropriately. The cracked wall around the door to bedroom 14 is repaired appropriately. During the inspection, it was noted that the hot water temperature in a number of hot water outlets in the bedrooms in the “new wing” unit did not meet the required standard of close to 43 Degrees C. The Registered Provider must ensure that the hot water temperature in ALL the hot water outlets in the home is maintained at the above required level at all times. The hot water temperature must be tested thoroughly on a weekly basis and identified problems must be rectified immediately and appropriate records maintained at all times. During the inspection, the home was found to be reasonably clean, tidy and free from any unpleasant odours. The home has good policies and procedures in place regarding infection control. It was evidenced from the staff training records that the majority of staff has completed training in infection control. All members of staff have received induction training and they are made aware of the dangers of cross-infection. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 and 30 The home is now adequately staffed at all times, which ensures the quality of care provided, and ability of the home to meet the needs of the service users. The home continues to support staff to complete training. The home has satisfactory staff recruitment policies and procedures. EVIDENCE: The information provided by the Registered Manager and available staff rotas showed that the home is now adequately staffed for 22 service users with varying degrees of dependency levels and differing needs. There are 4 carers and I senior carer on duty throughout the day and 2 night carers on wakeful duty and a senior carer/ manager on call. There are adequate numbers of ancillary staff on duty to cover cleaning, catering and laundry duties. The Registered Manager’ hours are in addition to the above staff hours and considered to be supernumerary to allow Mr Scott Taylor to manage the home efficiently and effectively. It was evidenced from the staff training records that 16 members of staff have completed their NVQ Level 2 and two carers have completed their NVQ Level 3 training. Three carers are currently undertaking NVQ Level 2 and two carers are in the process of completing NVQ Level 3 training. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 20 It was evidenced that the majority of the staff have completed their safe working practice topics training and those who as yet not received this mode of training must do so as a matter of priority. (See NMS OP38 below). Discussion with the Registered Manager and the examination of the most recently recruited staff files demonstrated that thorough recruitment procedures had been followed in accordance with the home’s recruitment policy. Two written references, Enhanced CRB and POVA checks are being undertaken before new members of staff are appoint It was evidenced from newly appointed members of staff files that the home is implementing the TOPSS Induction and Foundation training programme. It was also noted that the home has provided staff training in care planning, dementia care, abuse awareness and protection issues, care of dying and effective communication. Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 The home has good systems of communication in place to seek views of the service users and their families/friends. Money is well managed on behalf of the service users by the Registered Manager. Health, safety and welfare of the service users and staff are promoted by safe working systems put in place by the Registered Manager and the Registered Provider. EVIDENCE: The home has developed an annual quality assurance development plan. The Registered Manager has received completed questionnaires from the service users and their relatives, which gave feedback on the quality of service and facilities provided by Min-y-Don during 2005. The Registered Manager stated that a similar route would be followed to obtain feed back from other professionals, who visited the home. The feedback received would be analysed and a report will also be prepared with an action plan as appropriate. The Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 22 home needs to move swiftly in ensuring the early full implementation of this Standard. The Registered Manager continued to assist 18 service users with their monies. A sample of four service users’ money was checked and found to be satisfactory. The records of service users’ financial transactions are appropriately maintained. Accidents and fire prevention records were thoroughly examined, which were found to be appropriately maintained. All the matters pertaining to fire safety and environmental health were found to be satisfactory. However, The Registered Provider must ensure that those members of staff, who as yet have not received training in safe working practice topics, must do so as a matter of priority. (See NMS OP30 above). Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 X X X X 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement The Registered Provider must ensure that forecourt car park area is tarmaced and potholes are appropriately repaired for the safe use of service users and other visitors to the home. The damaged ceiling in the main lounge to be repainted and the carpet in main entrance doorway is replaced, and carpets in the main entrance hall and corridors and corridors in the “New Wing” unit are thoroughly and professionally cleaned. The Registered Provider must ensure that suitable tables to sit at in the remaining four bedrooms are provided; and that fused light bulbs in several bedrooms are replaced, and that new carpet in bedroom 5 is provided, and the cracked wall around the door to bedroom 14 is repaired appropriately. The Registered Provider must ensure that the hot water supply to all the hot water outlets in the new wing area of the home is maintained at all times at the required temperature level (i.e. DS0000064532.V272963.R01.S.doc Timescale for action 15/02/06 2. OP24 16 & 23 15/02/06 3. OP25 13 31/01/06 Min-Y-Don Version 5.0 Page 25 4. OP30 18 5. OP33 24 close to 43 Degrees C) for the safe use of service users and staff. The Registered Provider must ensure that all those members of staff who as yet not received training in safe working practice topics must do so as a matter of priority. The Registered Provider must ensure that an annual Quality Assurance development plan for the home is developed and fully implemented which must be based on a systematic cycle of planning, action, review, aims and objectives and outcomes for service users. 15/02/06 28/02/06 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 Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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 Min-Y-Don DS0000064532.V272963.R01.S.doc Version 5.0 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!