Inspection on 20/02/06 for Mona Cliffe Residential Care Home

This inspection was carried out on 20th February 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

Mona Cliffe Residential Care Home 19/09/06

Mona Cliffe Residential Care Home 31/10/05

Mona Cliffe Residential Care Home 25/10/04

Mona Cliffe Residential Care Home 19/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Mona Cliffe Residential Care Home Blackstone Edge Old Road Littleborough Rochdale Lancashire OL15 0JG Lead Inspector Jenny Andrew Unannounced Inspection 20th February 2006 09:30 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 Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 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. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mona Cliffe Residential Care Home Address Blackstone Edge Old Road Littleborough Rochdale Lancashire OL15 0JG 01706 372566 01706 372566 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) Dr Ravi Kant Sharma Linda Anne Belshaw Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of places 23, OP age 65 years and over Date of last inspection 31st October 2005 Brief Description of the Service: Mona Cliffe is a care home providing personal care and accommodation for 23 older people over the age of 65 years. The home is not registered to provide nursing care. Service users in need of nursing care would need to access the community nursing service. Mona Cliffe is located on the outskirts of Littleborough, with easy access to transport links such as the motorway, train station and bus station. The home is only a short travelling distance from facilities such as shops, restaurants, Hollingworth Lake, and the Pennine Way, although service users would not easily access these facilities on foot. The home is a large stone house, which has been converted and extended to provide residential care. It is set in its own grounds, with ample car parking available to the front of the home. There are 15 single rooms and 4 double rooms. The bedrooms are situated on the ground and first floor. There is a passenger lift. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took five and a half hours and was done by one inspector. The home had not been told beforehand that the inspector would visit. The inspector checked what was written down about the residents (care plans), looked around some of the building and also looked at a number of records. In order to get more information about the home, the manager, six residents, 2 care assistants, the cook, a domestic, 1 relative and the visiting District Nurse were spoken to. The inspector also watched how the staff cared for the residents. What the service does well: What has improved since the last inspection? The manager had been through all the home’s policies/procedures (documents which told staff how to do their jobs properly) and made changes as needed. The provider had improved the home’s fire safety system by fitting smoke seals to doors so that if there was a fire, smoke would not spread quickly. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 6 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. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 7 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 Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 8 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): Standard 3 was assessed at the last inspection and standard 6 is not applicable. EVIDENCE: Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 9 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&9 EVIDENCE: Three care plans were checked, including one for a resident who had only lived at the home for a week. The care plan for this person had been started and relevant assessments had been done. The manager was in the process of completing the care plan and social history as she got to know the resident better. The other two care plans were fully completed except for one which did not contain a social history. The manager said she was trying to arrange a meeting with the relatives so that she could agree the plan and obtain relevant information. The care plans were based on daily living activities and as a result of comments made at the last inspection, the manager had re-written the working/playing section to read social/spiritual needs. New sheets had been put into each of the care plans and key workers had been asked to speak to their residents in order to get up to date information about their spiritual needs together with hobbies/interests. The manager expected this to be done within the next week. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 10 Where the needs of residents are more complex, the manager is initially responsible for writing the care plan as was seen during the inspection. The recordings were detailed with an up to date evaluation about the person’s condition when discharged to the home from hospital. Progress made was also recorded. An additional section to the care plans had been introduced, where needed, looking at the psychological needs of individuals. It was evident that other professionals are consulted where problems are identified and in one care plan, it was evidenced the advice of a speech therapist had been taken. All visits of health care professionals are noted in the care plan file. The key workers are responsible for undertaking the monthly reviews as they are better equipped to note any relevant changes. It was noted that not all care plans had been signed by the residents or relatives and this should be addressed. From speaking to care assistants, it was clear they were familiar with the needs of the residents for whom they cared. One care assistant, who had only recently started working at the home had already read through all the care plans, paying particular notice of the needs of the person for whom she was the key-worker. Up to date risk assessments were in place in all 3 care plans for moving/handling, nutrition and skin care (Waterlows). Where other risk areas had been identified, for example smoking, risk of falls and the fitting of bed sides, risk assessments had been undertaken. Resident’s weights had also been recorded and were being regular monitored. A pharmacy inspector had undertaken a full inspection on 19 April 2005. On this visit, the requirements and recommendations made were followed up. All had been implemented and the system in place for the receipt, recording, storage handling and administration of medicines was found to be satisfactory. The home’s supplying pharmacist had made a routine visit on 9 November 2005 and found everything satisfactory. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 11 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 Provision of leisure activities was lacking, resulting in residents becoming bored and feeling unfulfilled. The dietary needs of residents were well catered for with a balanced and varied selection of food offered at each meal. EVIDENCE: All the residents spoken to were satisfied with their chosen daily routines. They said they could choose to get up and go to bed when they wanted, had choice of what to wear, where to eat, whether or not to use their room or the communal lounges and where to sit. The staff were also able to give examples of what choices residents were afforded. The care plans recorded residents’ likes and dislikes and 1 recorded that the person “didn’t like eating with other people”. Observations made during the inspection, showed that staff respected this persons wishes. Residents’ preferred rising and retiring times were also recorded on the care plans. Residents made varying comments about the activities and stimulation provided within the home. One person said “I get bored as there is nothing much organised”, another said “more could be done to keep us occupied” and a third person said, “the days seem very long”. Two residents, who spent time Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 12 in their rooms and enjoyed reading or watching television, said they were satisfied with their daily routines. There was a limited activities programme in place, which showed that reminiscence, hairdressing, nail and hand care and fortnightly bingo took place. An activities file did record some other activities, which were occasionally undertaken. Seasonal activities and special days were celebrated within the home e.g. Easter, Wimbledon, Remembrance Day, November 5th and Christmas. The home had also been busy fund-raising for several charities. From speaking to the staff, it was evident there was no-one responsible for undertaking activities and it was very much about doing something when there was time, without much planning or consultation taking place. As the residents presently living at the home have very differing needs and abilities, the key workers should spend time with their individual residents, finding out what sort of activities they would like to take part in. The programme should accommodate both individual and group activities and thought should be given to ensuring that those people who have memory loss are also catered for. In order to monitor the success of any programme which is implemented, the manager may wish to introduce activity sheets showing which residents had been involved in each activity and whether or not it had been enjoyed. Staff said they sometimes accompanied residents into the garden for some fresh air and a short walk. The manager had very recently applied for passes for the “Ring and Ride” service, so that some of the residents could attend a weekly local luncheon club. No trips out had been arranged over the last 12 months. One person said I’d like to go out to Hollingworth Lake or Hebden Bridge” and another person said they’d like more local trips out. Service users are encouraged to maintain contact with their family and friends. One relative was spoken to who said he was always made welcome and offered a drink. Residents may see visitors in the privacy of their rooms or, as on the day of the inspection, one person preferred to use the small conservatory. Involvement with local community groups accords with residents’ preferences. Over Christmas, a school choir and also a church choir visited the home and the residents said how much they had enjoyed this entertainment. Staff promoted and encouraged residents to be as independent as possible and exercise as much choice and control over their lives as possible. New residents are encouraged to bring small pieces of furniture and other personal possessions in with them so they can make their bedrooms homely and comfortable. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 13 On the day of the inspection, the kitchen assistant was standing in for the cook, who was on holiday. She was not keeping to the menu as she felt more confident cooking food she knew she was good at. This was acceptable as she had compiled her own menu for the week, which included nutritious and varied food. The 4 weekly menus inspected were seen to offer a good choice of nutritious foods at both lunch and teatime. Feedback from the residents spoken to was good with regard to the quality, quantity and variety of meals offered. The Inspector sampled lunch, which was braised steak and onions, boiled potatoes, broccoli and cauliflower followed by coconut sponge and custard. The steak was extremely tasty and very tender. The vegetables were rather over-cooked but the residents said they liked them soft. From observations made, it was clear they had enjoyed their meal as very little was left. Second helpings of meat were offered. The good practice of supplying residents with gravy boats and milk jugs, so they could retain some independence, was noted. Special diets were appropriately catered for i.e. diabetic, soft diets etc. The cook had used a sweetener in the custard so that it would be suitable for people on a diabetic diet. One resident required assistance at lunchtime and a care assistant spent time in the small lounge assisting her in a calm, unhurried manner. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 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): Standards 16 & 18 were assessed at the last inspection. EVIDENCE: Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 15 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): 26 The home was clean and hygienic and good infection control practices were in place, ensuring residents were protected as far as possible. EVIDENCE: Whilst a building inspection was not carried out on this inspection, requirements made previously in relation to the building were checked. The home had now complied with the GMC Fire inspection and fitted smoke seals to all identified doors, to stop the passage of smoke in the event of a fire. The requirements from the Environmental Health report had also been done and the home had been tested for legionella. Fourteen of the sixteen care staff employed had undertaken infection control training. Policies/procedures were in place for the control of infection and it was evident that staff were adhering to them. The home was clean and hygienic throughout and the staff were able to give good practice examples of how they ensured the spread of infection was minimised e.g. regular washing of their hands, use of disposable aprons and gloves, wearing of tabards for serving food and the use of red bags for carrying soiled linen to the laundry. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 16 Staff were seen to observe good hygienic practices during the inspection. Liquid soap and paper towels were available in bathrooms, toilets, the laundry and bedrooms. Staff also carried alcohol hand wash around with them so that they could use it when it was difficult to get to a wash hand basin. Laundry facilities were satisfactory and the industrial washer was equipped with a sluice wash. A laundry assistant was employed for 25 hours a week. and she was also responsible for ensuring that each resident had a clean towel and face cloth every day. One of the domestics was spoken to and she was clearly aware of each person’s individual preferred routine. She said those people who liked to stay in bed or in their rooms were not disturbed and that she fitted the cleaning around them. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 17 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 & 30 Staffing levels were satisfactory and there was a good match of well-qualified staff offering consistency of care to the residents. Good training opportunities were provided which enabled staff to strengthen and develop their skills and knowledge. The arrangements for the induction of staff were good, with the staff demonstrating a clear understanding of their roles. EVIDENCE: From checking staff rotas, it was identified that the staffing levels within the home were meeting the needs of the present resident group. The provision of ancillary staff was also satisfactory with 2 domestics, 1 laundry assistant, cook and kitchen assistant being employed. Feedback from residents was, in the main, positive with regard to the staff who they described as ‘very good’, ‘excellent’, ‘caring’ and ‘fine’. Two people did however, comment that “one or two staff need to have better manners” and “mostly good but some better than others”. The manager said she would follow up this feedback after the inspection. The staff turnover was very low and the team worked well together. Feedback from the manager and staff indicated that staff morale was good. The staff spoken to were knowledgeable about the needs of the residents in their care. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 18 The manager was committed to ensuring that the staff received the right training to care for the residents well. The training matrix showed that all, or the majority of staff had undertaken training in moving/handling, infection control, food hygiene, fire, health and safety and first aid. In addition the manager and 11 care assistants were presently undertaking a dementia training distance learning course, which was being piloted by Tameside College. The manager ensured that new staff were enrolled on the appropriate courses as soon as possible after commencing work at the home. Staff files also contained copy certificates confirming that all the above training had taken place. In addition to the above, new care assistants who had not previously worked in the care profession and did not have any NVQ qualifications, were enrolled on a care skills course. This included training in communication, hygiene, nutrition and pressure care and completion of the course gave them units to go towards their NVQ training which they were expected to take at a later stage. Eight of the present team had completed this course. The home had achieved 81 of staff trained to NVQ level 2. This is an excellent achievement and reflects the commitment to training by the provider, manager and staff team. The three staff who have not yet attained a qualification were due to be enrolled on courses over the next few weeks. The “Skills for Care” induction training for new staff was also in place and the most recently recruited staff, who had started work in January 2006 was in the process of completing it. The training record was in the staff’s personnel file and this person confirmed she had almost completed it. The manager had set up a system whereby staff without any qualifications or previous experience would undertake the full induction course but those with qualifications and experience would undertake one she had formulated herself based on the “Skills for Care” format. It was clear that all staff had benefited from more than 3 days paid training over the last 12 months. Whilst staff recruitment was not inspected on this occasion, the requirements made at the last inspection were followed up and found to have been met. It was however, noted that staff files did not all contain identity photographs and this must be addressed. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 19 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 The manager provides strong leadership, guidance and support to staff to ensure residents receive a consistently good standard of care. Quality monitoring and reviewing processes were in place to ensure the home is run in the best interests of residents. The systems in place to safeguard residents’ financial interests were satisfactory. Whilst a supervision system was in place, more regular meetings need to take place in order that staff performance may be consistently monitored. EVIDENCE: Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 20 The manager is registered with the Commission For Social Care Inspection. She is a Registered Nurse with experience in the National Health Service and private sector. She has undertaken regular clinical updates relevant to her working environment e.g. Protection of Vulnerable Adult training and dementia care. She successfully completed her NVQ level 4 care award in 2003, followed by the Registered Managers Award in 2004. From interviewing staff and records seen, it was evident that the manager actively promoted staff training and development opportunities as already highlighted above. She has a good understanding of the areas in which the home still needs to approve and was committed to addressing the identified shortfalls. Feedback from both staff and residents was positive. Staff said she was “supportive” and “approachable” and residents said she “was good at her job” and “that if they had any problems she would put things right”. The home achieved the “Investors in People” award 3 years ago and their reassessment review was due to take place in May 2006. The home’s quality assurance questionnaire, which is circulated to residents and visitors, had been reviewed and the results from the latest survey had been sent to the Commission for Social Care Inspection. The questionnaire covered overall service, level of professionalism, level of care offered, activities and stimulation, standard of food and variety of menu, attitude of staff, level of staff training, environment and pricing mechanisms. Overall, feedback was generally positive. Discussion took place about the possibility of formulating a feedback questionnaire for other visitors to the home i.e. district nurses, Doctors etc. and the manager said she would consider this. Resident meetings also took place. As part of the quality assurance system, the manager had formulated a staff questionnaire in relation to her role as manager. This had been circulated to the staff and the feedback was to be used as part of her appraisal process with the provider. She had also reviewed and updated her policy/procedure manual. Whilst a supervision system was in place, records showed that the manager was not meeting the standard of 6 supervision meetings per year. All staff had however, received their annual appraisals. The manager needs to implement a system whereby she achieves her supervision target and may find that as well as individual supervision sessions, group supervisions could also be done. It was also noted that staff meetings are not held on a regular basis and this should be addressed. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 21 The home does not get involved in the handling of residents’ finances, except where residents and/or their relatives request it. Small amounts of money may be deposited and in these instances, a system was in place to account for income and outgoings. Receipts are retained for any purchases made on behalf of individual residents. Secure facilities are provided for the safe keeping of money and valuables with limited key holders. The records of 3 residents were checked and all found to be in good order. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 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 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X X Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 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 OP12 Regulation 16 Requirement An activities programme must be formulated and implemented which meets the needs of all residents, including those who are mentally frail. Staff files must contain an up to date photograph for identity purposes. Timescale for action 31/03/06 2. OP29 19 31/03/06 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. Refer to Standard OP7 OP12 OP24 Good Practice Recommendations Care plans should be done in consultation with residents and/or their relatives who should sign to say they are in agreement with them. In accordance with resident’s wishes, more local trips out should be arranged. Safety locks, which can be operated by a key should be fitted to bedroom doors. (Outstanding from the last inspection). A minimum of 6 supervision meetings each year should be DS0000017348.V281595.R01.S.doc Version 5.1 Page 24 4. OP36 Mona Cliffe Residential Care Home held and more regular staff meetings arranged. Mona Cliffe Residential Care Home DS0000017348.V281595.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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