Inspection on 17/05/05 for Moor Villa

This inspection was carried out on 17th May 2005.

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

Moor Villa 15/04/08

Moor Villa 17/07/07

Moor Villa 02/10/06

Moor Villa 20/09/05

Moor Villa 18/08/04

Moor Villa 16/06/04

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

CARE HOMES FOR OLDER PEOPLE Moor Villa 53 Moor Street Kirkham Lancashire PR4 2AU Lead Inspector Denise Upton Announced 17 May 2005 th 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 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. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Moor Villa Address 53 Moor Street Kirkham Lancashire PR4 2AU 01772 682 884 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Savitree Seedheeyan Mrs Christine Harris Care Home only 16 Category(ies) of Dementia (16) registration, with number of places Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2004 Brief Description of the Service: Moor Villa is registered accommodate up to 16 service users of either sex who have a diagnoses of dementia. The home is conveniently located on a main thoroughfare of the town and in close proximity to local community services and resources. Moor Villa is a detached property with communal space consisting of a large combined lounge/dining room and a small separate lounge area. Individual bedroom accommodation is located on the ground and first floor of the property and comprises of 8 single bedrooms and 4 shared rooms. Although en-suite accommodation is not provided there are sufficient bathroom and toilet facilities to fulfil the requirements of the standard. Visitors are made welcome at any time of the service user’s choice. Aids and adaptation are provided as required and all service users have access to appropriate medical interventions. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a day and part of another day and in total spanned a period of 9 hours. The inspector spoke with the home’s register manager and individual discussion also took place with 4 of the 14 residents living at the home and three members of the care staff team. Unfortunately conversation with three of the service users individually spoken with was limited because of difficulties with short-term memory loss however these people were very relaxed and comfortable and said they were happy living at the home. Although on this occasion discussion did not take place with any relatives, six Commission For Social Care Inspection comment cards were completed by relatives/friends of residents living at the home prior to the inspection-taking place. A number of records, including care records and policies and procedures were also examined and a tour of the building and outside area also took place. What the service does well: This home has a group of staff that have worked at the home a long time and know the service users well. They are keen to provide a good quality of care and are undertaking a variety of training to make sure they have sufficient skills and knowledge. A resident spoken with felt that staff had built up a good relationship with service users and work hard to make people living at the home feel safe and comfortable. Meals are varied, well balanced and nicely presented offering some choice. Staff take care to ensure that meal times are a social occasion and assist residents that need help with meals in a sensitive way. Comments from service users about meals and mealtimes were very positive with residents who were eating in the dining area at the time of the inspection, clearly enjoying their meal and comfortably chatting amongst themselves and with members of staff. Routines within the home are flexible to make sure people who live there can, as far as possible, enjoy of lifestyle of their choice. Residents are encouraged to have there say and there is a friendly relationship between staff and relatives who can visit at any time. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: There are a number of things that the owner and manager can do to make the home more comfortable and to make sure there is enough written information about the things people living at the home can do for themselves without any help and the things that people need help with including social interests, outings and hobbies. The outside of the home and some of the inside of the home still needs attention to provide a more attractive, welcoming and comfortable environment for residents to live in. Some of the written information about the staff who are on duty at any particular time needs to be improved and the basic initial training for newly appointed staff needs to be checked against the nationally recognised training organisation recommendations to make sure staff receive appropriate training. In addition, the next stage training for recently appointed staff should be made available. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 7 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. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 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 standard(s) 3 The home has a good system in place of assessing the strengths and needs of prospective new residents that includes information obtained from other professionals involved. This enables an informed decision to be taken about whether the home can adequately address current strengths, needs, wants and wishes. EVIDENCE: Since the last inspection, a new pre admission assessment document had been devised that is comprehensive and provides a holistic overview of the prospective service users current strengths and needs. It was evidenced that this document had been implemented in respect of the most recently admitted service user and the information obtained, along with the Health and Social Services care management assessment and Care Programme Approach care plan had provided sufficient information for the registered manager to make an informed decision as to whether the home could address current requirements. An initial risk assessment process had also been undertaken. This collated information provided the basis of the initial care plan. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 Although there is a care planning and review system in operation at the home, a consistent approach to these tasks is not always evident. In consequence, on occasions, staff are not provided with the up to date written information they need to satisfactorily meet service users needs and are dependent on informal word of mouth information sharing. EVIDENCE: All service users at Moor Villa have an individual plan of care that is devised from the assessment process. However information obtained from the initial assessment of strengths and needs and risk assessment process is not consistently incorporated in the individual care plan. It is essential that the individual care plan reflects all elements of the service user’s strengths, needs, wants and wishes that includes current health, personal and social care requirements. It is also recommended that the plan of care be further expanded to identify how a specific task is to be achieved and the actual assistance required by staff to fulfil the objective. Likewise, although a risk had been identified and a formal risk assessment undertaken, the outcome of the risk assessment has not been routinely incorporated in the individual plan of care. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 11 Although it was clear that wherever possible service users with mental capacity sign their individual care plan and all service users have their care plan verbally explained to them by staff, it was evident that care plans are not formally reviewed on a monthly basis. On two of the service users case files that were ‘case tracked’ during the course of the inspection, a period of almost twelve months had elapsed between one formal review of care and the following review of care. In one of these cases it was established that the service user had been admitted to hospital and discharged back to the home but this was not indicated on the care plan or any detail of additional support that may have been temporarily required on discharge. Whilst there is no suggestion that the service user did not receive the care and support required, this was achieved by word of mouth information sharing within the staff team rather by maintaining the required written information on the care plan. Service users spoken with during the course of the inspection were all very pleased with the level of care provided by the staff team with one comment on the Commission For Social Care Inspection relative comment card that stated ‘ “My mother feels at home and I am confident that she receives the care she needs”. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users taste and choice. EVIDENCE: Menu plans observed at the time of inspection reflected that a varied and nutritionally balanced diet is offered to residents that is devised in consultation with service users. However there is flexibility to alter the planned menu dependent on the fresh foods available on a particular day, the weather and what service users decide what they would like to eat for any particular meal. Specialist diets in respect of medical, cultural or religious requirements can be catered for. It was observed that meals are viewed as a social occasion and that staff who assisted service users to eat, carried out this task in a sensitive and unhurried manner that respected the service user’s dignity. Comments overheard from service users during the course of the meal about the food served were all very positive and complementary and the interaction between staff and service users at mealtimes was ‘chatty’ and comfortable. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 & 18 Although no complaint has been received for a considerable period of time, the home has a satisfactory complaints system and adult abuse policy and procedures in order to protect service users and ensure residents and their relatives know how to make a complaint. EVIDENCE: There is a clear and simple complaints procedure that is incorporated in the Statement of Purpose and Service User Guide to inform service users and their family of how a complaint can be made and the process of investigation including a maximum timescale of when the complaint will be responded to. It is understood that following a recommendation in the last inspection report, the complaint record form has been revises to specify more detail however this document was not available at the time of inspection. Moor Villa has also produced an adult abuse policy and procedures and a whistle blowing policy to ensure the safety and protection of residents. In addition, the majority of staff have now undertaken adult abuse training. However further policies in respect of physical and verbal aggression, service user monies and valuables and precluding staff involvement in the making or benefiting from service user’s wills should be developed. This would ensure all staff are clearly aware of the home’s policy in respect of these issues and also provide further protection for service users and the staff team. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19,20,22,24,25 and 26 The physical environmental standard of the home both internally and externally requires improvement and refurbishment. Although some limited progress has been made since the last inspection in providing an improved safe, homely and comfortable environment, further investment is required. However there is evidence of further planning to improve the physical environment of the home to enhance the living accommodation of residents. EVIDENCE: Although some of the recommendations identified in the last inspection report have been addressed, further action is still required. All radiators in service user accommodation have now been fitted with guards to prevent the risk of accidental burns and thermostatic devises have been fitted to hot water outlets to prevent the risk of accidental scalding. In addition, window restrictors have been fitted to the majority of windows in order to protect service users from harm. The required work to an external area of the building above the patio doors has been completed however the external environment especially some window frames and the external paintwork still required attention. The laundry Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 15 area, situated in an outhouse, also required attention to the walls, ceiling and floor to ensure it is in good order and easily cleanable. With regard to the internal environment, the Fire and Rescue Service conducted a recent inspection and as a result, fire precautions in the home needed to be significantly improved. This work is currently ongoing. It is understood that once this required work is completed, the internal environment of the home will be redecorated and re-carpeted. In response to the Fire Service report, all doors and doorframes are to be replaced in order to be compliant with fire safety requirements. Once the new doors are fitted, it is understood that all individual bedrooms in service user accommodation will be fitted with an appropriate locking mechanism as recommended in the last inspection report. A locked facility for the safe storage of personal items has now been provided in individual bedroom accommodation. A number of aids are provided to promote independence and an intercom call bell system is provided in all bedroom accommodation. It is understood that the call system is to be extended in the near future to incorporate communal areas of the home. In order to ensure there is no possibility of compromising service user’s privacy, it is recommended that the existing intercom system be replaced with a call bell system with an accessible alarm system. The environment was discussed with residents spoken with and one resident said he would like a lock on his bedroom door to prevent other service users accidentally going in especially at night. Comments made by a relative of a service user on the Commission For Social Care Inspection comment card completed prior to the inspection stated that, ‘ The care and staff are second to none. The owner needs to decorate in some areas to keep up with the standard of care the staff give’. Staff also commented on the improving environment although stated this was a slow process. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 & 30 The home enjoys a stable staff group who offer consistency of care to service users accommodated. Staff morale is high and staff have a good understanding of the service users support needs. This is evident from the positive relationships, which have been formed between the staff and service users. Staff training has been given some priority. This will help provide staff with the skills and knowledge to provide a high quality service. EVIDENCE: Since the last inspection no new staff have been appointed. However a recruitment policy and procedure has recently been devised along with a comprehensive job application pack. The process will include obtaining the required references/clearances including a Criminal Records Bureau clearance. A staff rota is now available however the name or initials of the actual member of staff on duty needs to be identified for each shift period rather than just the designated role of the staff member in question. Also the rota must identify the week in question and must be amended to identify if a member of staff did not work their shift for whatever reason and the name or initial of the individual who covered that shift period. Staff training has been given some priority with the majority of staff now undertaking nationally recognised NVQ training at various levels in additional to a variety of other training topics. Although currently only one member of the care staff team has achieved an NVQ Level qualification, four further members of staff are currently undertaking Level 3 of this award and one member of Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 17 staff is undertaking Level 2 accreditation. In addition a further member of staff is undertaking the Registered Managers Award. Although the home has an induction-training programme available for newly appointed staff, it was evident that this is not compliant with TOPSS specification in respect of induction standards. The existing induction-training programme should be evidenced against TOPSS standards to ensure compliance. In addition, foundation training has yet to be developed to TOPSS specifications. Staff individually spoken with stated they were enjoying the training provided although it took up a lot of time. Staff spoken with also stated that they were very happy working at the home and enjoyed ‘making the service users happy’. This included sitting and talking with residents and getting to know them really well. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 33 The registered manager is competent and experienced but does not wish to undertake additional care and management training. This potentially leaves service users at possible risk as current best practice principles, understood through an advanced level of care and management training, cannot be cascaded to staff or staff performance in terms of best practice effectively evaluated. The systems for service user consultation are limited because of the cognitive impairment of the majority of service users accommodated. However informal systems are evident for service users and relatives to make their views known. EVIDENCE: The registered manager, although competent and experienced does not want to pursue a NVQ Level 4 qualification in care and management or undertake the Registered Managers Award. At this present time the registered manager is currently undertaking additional duties within the company in addition to the registered manager’s role at the home. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 19 Whilst it is recognised that a registered manager in day to day control of a care home would normally work a minimum of 35 hours a week undertaking direct management tasks, the registered manager is currently only working about 30 hours a week on a full time basis at Moor Villa. Whilst it is understood that this is viewed as a temporary arrangement, the Commission For Social Care Inspection need to be informed immediately should the number of hours worked by the registered manager in direct management tasks at the home fall below the hours currently worked. Currently the deputy manager is undertaking the Registered Managers Award and it is understood that at some time in the future, consideration may be given to a change of registered manager. However the person appointed would be required to have a wide range of skills and knowledge relating to management role and care of service users in the dementia care category and fulfil all the requirements in respect of a registered manager in relation to the Care Standards Act 2000. Because of the cognitive impairment of the majority of service users accommodated, written questionnaires for service users are not effective and a verbal approach is in the main used to elicit service users views and influence change. Likewise informal verbal discussion is used to obtain the views and opinions of relatives and other stakeholders in order to identify how the home is achieving goals for service users. To develop this informal process further, consideration should be given to introducing anonymous questionnaires for family, friends and other stakeholders as this will also inform the internal quality assurance audit and consideration should also be given to introducing an external professionally recognised quality assurance system to supplement the internal process. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x 3 x 2 3 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x 3 x x x x x Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 21 Are there any outstanding requirements from the last inspection? 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 1 Regulation 4&5 Requirement Timescale for action 31/07/05 2. 27 Reference must be made to Regulations 4 & 5 and Schedule 1 of the Care Homes Regulations 2001 and Standard 1, National Minimum Standards, Care Homes for Older People to ensure compliance.(Timescale of 31/10/04 not met) Schedule The staff rota must indicate the 30/06/05 4 Care week the rota refers to and Homes specify the name/initial of each Regulation member of staff on duty during s 2001 each shift period. Any changes to the stff rota for that particular week must also be identified. (Timescale of 30/09/04 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations Care plans should be further developed. Formal risk assessments should be conducted in respect of all identified risks with outcomes incorporated in the care plan. The care plan should be holistic and identify all medical, personal and social strengths and needs. F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 22 Moor Villa 2. 18 3. 19 4. 5. 22 24 6. 25 7. 26 8. 9. 28 30 10. 11. 31 33 12. 38 Further documents should be developed in respect of physical and verbal aggression, service users monies and financial affairs, service users access to their personal financial records and staff not becoming involved in the making or benefiting from service user wills. Attention should be given to the internal and external environment of the property and the programme of internal redecoration continue. The maintenance plan should indicate the proposed time scale for the work to be undertaken and dated when the required work has been completed. It is recommended that the intercom call system in all service user accommodation be replaced by a call bell system with an accessible alarm facility. The programme of fitting an appropriate locking mechanism to individual bedroom accommodation should be continued until completed. Window coverings should be fitted to skylight windows in two bedrooms and at least two double electric sockets should be provided in all service user bedroom accommodation. Water temperatures from hot water outlets in all service user accommodation should be tested on a regular basis to ensure a consistant temperature is maintained. Considerstion should be given to replacing the remaining strip lighting to more domestic type lighting in service user accommodation. Consideration should be given to retreating the laundry room floor and that the walls and ceiling of the laundry room be given some attention to ensure they are in good order. The waste management policy should be personalised for the requirements of the home and policies developed in respect of protective clothing and hand washing. At least 50 of the care staff team should have attained NVQ Level 2 by 2005. The current induction training programme should be evidenced against TOPSS specifications to ensure conpliance. Foundation training to TOPSS specification should be developed and introduced. The registered manager should have obtained an NVQ in care and management or equivalent by 2005. The quality assurance system should be further developed and consideration given to introducing an external professionally recognised quality assurance system to supplement the internal process. A qualified first aider who has undertaken additional training should be on duty at all times. All staff should complete the planned infection control training. The F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 23 Moor Villa current Health and Safety policy shoule be personalised to the requirements of the home and up to date risk assessments undertaken in respect of all safe working practices. Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unit 1, Tustin Court Portway Preston PR2 2YQ 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 Moor Villa F57 F09 S9722 Moor Villa V197752 170505 Stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!