Inspection on 05/10/06 for Norfolk Villa

This inspection was carried out on 5th October 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

Norfolk Villa 12/01/06

Norfolk Villa 12/07/05

Norfolk Villa 15/12/04

Norfolk Villa 29/06/04

Norfolk Villa 21/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Norfolk Villa 45 Alma Road Pennycomequick Plymouth Devon PL3 4HE Lead Inspector Megan Walker Key Unannounced Inspection 5th October 2006 12:00 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 Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norfolk Villa Address 45 Alma Road Pennycomequick Plymouth Devon PL3 4HE 01752 661979 01752 668072 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) Mr Robert Timothy Teasdale Mr Robert Timothy Teasdale Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 19 residents are accommodated in the home at anyone time 1 named Service User over 65 with a learning disability Date of last inspection 12th January 2006 Brief Description of the Service: The home is a large detached building over 150 years old. It is located in the Pennycomequick area of central Plymouth. A full range of amenities and facilities are within walking distance of the home, including bus routes and Plymouth railway station. The home provides accommodation for up to nineteen residents. It has been extended over they years and currently has nineteen single bedrooms, eleven of which have en-suite toilet facilities and two have en-suite bathroom/shower facilities. There are two communal bathrooms in the home, one of which has a Parker Bath for those residents requiring assistance with bathing. The main lounge is in the extension on the ground floor at the rear of the building. There are two dining areas one in the older part of the building and the other at the rear of the sitting room. There are small gardens to the front of the building and to the side of the extension. The bedrooms are both on the ground and first floors of the building. Stair lifts provides access to the first floor although some mobility using stairs is required by residents due to small flights of stairs between corridors. The home has a No Smoking policy. The current fees range from the local authority rate of £273 up to £320 for people who are self-funding. Additional charges include hairdressing, chiropody, dentist, newspapers, toiletries, and outside activities. The Registered Provider provided this information in August 2006. The home is registered to provide care and accommodation for older people. It does not provide intermediate care and it is not registered to provide nursing care. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit of this inspection took place on 5th October 2006 over a period of about eight hours. It included a tour of the premises, observation of staff and residents in the home, case-tracking residents, inspection of cares plans, staff files, medication, and other records and documentation, talking to residents and to staff. The Registered Provider was present at the time of this inspection visit, and part of the time was spent talking with him about the running of the home. Also the home’s staff trainer, the Senior Deputy Matron and one of the Deputy Matrons provided explanations about care management within the home, staff training and development, and staff supervision. In addition other information used to inform this inspection included the Preinspection Questionnaire completed by the Registered Person, Comments’ Cards from five relatives, and five Care Workers Surveys. Also taken into account were the previous two inspection reports and all other information relating to Norfolk Villa received by the Commission since the last inspection. Two requirements and three “Good Practice” recommendations were made as a consequence of this inspection. What the service does well: What has improved since the last inspection? The knives identified at the last inspection as being a danger due to their location in the kitchen have been moved to a more suitable and safer place. Vinyl flooring has replaced carpets in all the toilets, and other carpets identified at the last inspection as being worn have been replaced. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 6 A Residents’ Forum has been set up to meet once a month. This is formally chaired and minutes of the meeting are taken. A staff training and development plan has been devised and will be formally introduced in the near future. A new routine to meet the “Safer Food, Better Business” regulations is to be introduced to all staff as part of their training programme shortly, after which the Registered Provider proposes to review it periodically. 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. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 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 Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 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): 1, 3, 5 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families can feel confident that their needs will be assessed before moving into the home and that they can have the information they need to make an informed choice about where to live. EVIDENCE: The Registered Provider stated that anyone making enquiries about Norfolk Villa would be told about the home’s website, and also referred to the CSCI website to download the home’s reports. He also said that if he had a copy of the last inspection report available, he would give this to a prospective resident and/or their family to read. A sample advertisement for the home was also seen during this visit. The Registered Provider explained that it was brief because he preferred prospective residents to actually visit the home and “see it for themselves”. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 9 One resident who spoke to the inspector explained how he had chosen the home and this included visiting before deciding to move in here. Other residents said that their families had chosen the home for them nonetheless it had been a good choice. All the care files inspected had an assessment of need and a care plan to meet those needs. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can feel confident that a staff team that is respectful and reliable will ensure that their care needs are met. EVIDENCE: Since the last inspection the detailed format for individual residents’ care plans has been put into practice, however of the files inspected, not all of them were completed. Where staff had identified specific risks to an individual, there were appropriate risk assessments on the file. There were records of any accidents on each file with detailed information to support the information recorded in the accident book. If the information was available, the care plans had details of specific wishes regarding preferences for funeral arrangements. The medication is kept in a fixed lockable cupboard, and there is a separate fixed lockable box for any controlled medication. For a number of practical reasons the staff responsible for medication have opted for a more traditional system of medication storage and handling. This has proven to be a safe and reliable method for Norfolk Villa. Four staff members have done training on “Administration and Safe Handling of Medicines”, and are responsible for Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 11 dispensing medicines to residents. At the time of this visit, one resident was self-medicating, and another resident was responsible for his or her own inhalers and nebuliser. Several residents spoke to the inspector about their experience of living at Norfolk Villa and they were satisfied that their needs were met, and that the staff looked after them as they wished. During the tour of the premises residents were seen in their rooms, some with their doors open. One resident commented that it was personal preference to have the door open and to “put up with the hustle and bustle” rather than close it and feel isolated. Another resident also expressed a preference to remain in her room with the door open during the day. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are satisfied with their lifestyle at Norfolk Villa. EVIDENCE: The residents living at Norfolk Villa at the time of this inspection visit had varying levels of mobility consequently some continue to independently participate in activities outside the home. One resident talked to the inspector about bus trips using a “”Rover” bus pass; another resident regularly attends home matches at the local football club; and there is a local shop that some residents are able to walk to for their newspapers and other sundries. Families and friends are encouraged to visit their relative living at the home, and residents maintain contact with friends and families. During this inspection visit several residents talked to the inspector about their families and the contacts that they each had. When it was possible family members could eat with their relative at the home, usually in their room for privacy. One resident told the inspector that she had a mobile telephone so that she could have regular contact with her family. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 13 On the day of this inspection visit the midday meal was stew and dumplings with fresh vegetables followed by rice pudding suitable for diabetics. The Registered Provider confirmed that every day there were several alternatives for pudding including fresh fruit or ice cream and wafers. The decision for the main course was based on a majority vote as each morning the residents were given a choice of ways in which the meat could be cooked, e.g. turkey casserole or turkey pie. The Registered Provider explained that he planned the meat and vegetables for the week however not how it would be cooked. He also said that the residents tended to be conservative in their preferences, “meat and two veg’”, although he had tried to introduce Spaghetti Bolognese, and a few residents enjoyed curries. Another member of staff independently commented that “a Sunday Roast was expected” by the residents, even during high temperatures over the summer months. A few staff commented in the Care Workers Surveys that the residents had a good diet “ a good menu of food, fresh veg which is essential in their diets and well-being”: “residents get good fresh home cooking”. All the residents asked about food said that it was “excellent”. In the minutes of the last Residents’ Forum it was recorded that a resident had asked for home baked cakes suitable to be eaten by people with diabetes. The Registered Provider confirmed that he was taking up the challenge! Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families and friends can feel confident that any issues of concern or complaints raised by them will be dealt with appropriately. EVIDENCE: Since that last inspection the Commission has not received any complaints about Norfolk Villa, however the Registered Provider stated that he had received five internally, three of which were substantiated. He clarified that these were complaints by residents about food and on each occasion the matter had been resolved. The Registered Provider stated that the Residents’ Forum was proving to be a good way for residents to raise issues and these could then be dealt with accordingly. He also confirmed that should a relative raise anything with himself or the staff team, he would endeavour to sort out the matter. All the staff at Norfolk Villa have done “Safeguarding Adults” training although the Registered Provider expressed his concern that they are still awaiting their certificates of attendance despite his several telephone calls to the course organiser. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 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): 19, 20, 21, 23, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Norfolk Villa is a homely place where residents can arrange their bedrooms to suit their individual preferences and needs. EVIDENCE: A tour of the premises found it to be in good order. Some of the bedrooms had been redecorated since the last inspection and one resident told the inspector that she had chosen the colour for her room. New carpets had been fitted upstairs on the landing and in some of the bedrooms to meet a requirement from the last inspection. Non-slip vinyl had been fitted in all the toilets instead of carpets for reasons of hygiene and infection control. The carpet in the main hallway and on the stairs was found to be well worn however the Registered Provider stated that he was aware of this although there were no plans to replace it in the near future. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 16 Each bedroom seen was personalised and some residents had brought in pieces of their own furniture. Other residents had soft furnishings of their choice around their rooms. The bedroom doors upstairs have had replacement handles to comply with regulation about lockable doors. Whilst this is commendable, the doors had not been “made good” so they all looked shabby. The sitting room was comfortable and informal in character. The Registered Provider commented that rather than tidy it all away, he liked to encourage residents to leave their bits and pieces (knitting, newspapers, magazines, etc) around the room as they may have done when living in their own homes. At the front of the property trees had been removed because their roots were causing structural damage. The Registered Provider explained about this, and also that he was currently looking into the cost of a tarmac path to the front door since the last Residents’ Forum. The minutes of that meeting showed that residents were concerned about the cobbles becoming slippery particularly when the leaves started falling and became wet. Handrails had been suggested; however the Registered Provider felt replacing the cobbles would be a safer option. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 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, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by trained and motivated staff in sufficient numbers to meet the needs of those currently living in the home. EVIDENCE: At the time of this inspection nineteen people were employed to work at Norfolk Villa. The Deputy Matron explained that apart from the seniors, all staff worked on fixed days that suited their preferences and personal commitments. Most staff had opted for a twelve-hour shift pattern as it also allowed more flexibility outside work. The senior staff worked a three-week shift pattern so they would work with all staff at some time during this three-week period. The Deputy Matron felt that this practice worked well because it meant everyone was used to working with each of the three Deputy Matrons, and it prevented any potential team rivalry. Staff team meetings are held bi-monthly or adhoc if any urgent matter arises. Minutes are taken at these meetings. The Registered Provider confirmed that the issues raised by staff at the last inspection regarding their breaks had been discussed with them. He confirmed that he would allow staff to leave the building during their breaks as long as there was sufficient staff on duty. He also stated that staff preferred to take their breaks together, therefore he had made an agreement with them that they could do so as long as they remained Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 18 on the premises and responded to residents or visitors or any other interruption during the break. The Registered Provider positively promotes non- discriminatory practice in allowing people to continue to work at the home for as long as they are able after the recognised age of retirement. All the staff were seen wearing name badges that were written with letters large enough to be read by anyone with a sight impairment. The badges were also worn in a prominent place again so they could be seen easily. Six staff members completed NVQ courses ranging from 2 to 4 over the past twelve months. One staff member is currently taking NVQ Level 5. Five staff had started work at the home since the last inspection and the home’s trainer confirmed that they had all completed the home’s induction course. The trainer outlined plans she had for implementing the “Skills For Care” induction training, and how this would be used for all staff as an in-house “refresher” course. Inspection of staff files found that they were incomplete, for example, there was no proof of identity. The Matron confirmed that this would have been seen for the CRB check. The residents who spoke to the inspector about living in the home all praised the staff and were very complimentary about them. The Care Workers Survey had a question: “Is there anything that the home does really well that you would want to tell us about?” Written responses from care staff at the home included: “The residents well being – be it social or medical, it’s always a priority”. “The home is so friendly and happy I’m glad I work here” “The management and staff try hard to keep a good balance of caring and to have fun times”. Observation of the interaction between the staff and the residents saw staff being respectful towards the residents, assisting them as required, and in a sensitive manner. There was also light-hearted chatter between the residents and the staff, and residents did not appear to be intimidated by any of the staff team. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 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, 37 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health, safety and welfare is promoted and protected by a competent and capable Registered Provider who is keen to achieve positive outcomes for residents and staff. EVIDENCE: The Registered Provider is popular and approachable. This was shown in staff and relatives’ Comments’ Cards, conversations with staff and residents, and observation during this inspection visit. The home is run in an open and transparent way with responsibilities delegated appropriately amongst staff. A Residents’ Forum has been introduced and two meetings had taken place by the time of this inspection visit. The minutes of these meetings were seen, and the Registered Provider explained action and outcomes as a consequence of any matters raised by the residents. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 20 The Registered Provider stated that formal questionnaires were sent out periodically and were also available near the front door for visitors to complete. He admitted these were rarely completed and returned. He also stated that he endeavoured to always respond to relatives who raised any matters of concern, however this was not always recorded. As a measure of the quality of the home the Registered Provider explained that he uses staff training, supervision, complaints/concerns, CSCI inspections and the Residents’ Forum. It was agreed during this visit that these would be put together into a formal quality assurance review. At the time of this inspection visit the home was not responsible for any residents monies. The home’s trainer outlined plans to introduce a regular supervision programme for all staff and how this would be put in place in the near future. The Registered Provider confirmed that all the necessary maintenance checks as reported in the Pre-Inspection Questionnaire were correct and up to date. A Fire Safety Consultant had visited on the day of this inspection visit and his report stated: “The manager and staff are trained and aware of their actions in the event of a fire. The fire safety management is in order.” The Registered Provider attended a seminar on “Safer Food, Better Business” recently and he plans to implement a new kitchen routine that will comply with the Food Standards Agency regulations and recommendations. Three members of staff including the Registered Provider have attained NVQ Level 4 in Care, one staff member has NVQ Level 3 in Care and eight staff members have NVQ Level two in Care. Two other staff members plan to start an NVQ Level 2 in the future, and the home’s trainer is currently taking NVQ Level 5. Three senior staff have completed “Administration and Safe Handling of Medicines” and three others are awaiting a course. All staff receive mandatory training as required as part of an in-house training programme that is currently under revision by the home’s trainer, and shortly to be replaced with a new programme. During the tour of the premises cleaning materials were found in one of the bathrooms. The matron was made aware of this at the time. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 21 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 4 X 3 X 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 2 3 4 X 4 4 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X 2 X N/A 2 X 2 Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 22 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 OP29 Regulation Sch2 Sch 4 13(4) Requirement The Registered Provider must ensure that all staff files have the documentation as required in these schedules. The Registered Provider must ensure that hazardous substances including cleaning materials are not left unattended anywhere around the home. Timescale for action 31/12/06 2 OP38 05/10/06 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 Refer to Standard OP19 Good Practice Recommendations The Registered Provider should “make good” bedroom doors that have had replacement door handles and locks. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 23 2 OP33 3 OP36 The quality assurance system should continue as discussed during this inspection visit to be developed to establish the residents’ level of satisfaction with the care services they receive in the home and extended to all visitors to the home including health and social care professionals, to establish their level of satisfaction with the care services being provided in the home. The results of all the surveys undertaken must be published and made available to prospective service users and the Commission. The Registered Provider should continue with the proposed plan to implement regular recorded staff supervision. Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Norfolk Villa DS0000003485.V308225.R02.S.doc Version 5.2 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. 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