Inspection on 03/10/06 for Norlington Care Home

This inspection was carried out on 3rd 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Norlington Care Home 10/09/09

Norlington Care Home 19/09/07

Norlington Care Home 15/05/07

Norlington Care Home 18/05/06

Norlington Care Home 14/11/05

Norlington Care Home 01/06/05

Norlington Care Home 11/02/05

Norlington Care Home 22/06/04

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 Norlington Care Home 19 Stourwood Avenue Southbourne Bournemouth Dorset BH6 3PW Lead Inspector Chris Gould Unannounced Inspection 3rd October 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000055350.V315129.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. DS0000055350.V315129.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norlington Care Home Address 19 Stourwood Avenue Southbourne Bournemouth Dorset BH6 3PW 01202 422064 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) Norlington Care Limited Mrs Carolyn Mary Jolliffe Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places DS0000055350.V315129.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration 1. No more than 20 service users in need of nursing care may be accommodated. 18th May 2006 Date of last inspection Brief Description of the Service The Norlington Care Home is registered to provide personal care for up to 37 older people, 20 of whom can require nursing care. Mrs June Tempany and her son Mr Gary Tempany own the home. Carolyn Jolliffe has been registered by the Commission for Social Care Inspection as the manager. Norlington Care Home is situated on the edge of Southbourne and is close to local shops and amenities such as libraries, churches etc. and also to the sea and cliff top walks. There are single and double rooms on the ground, first and second floors. A lift provides level access to all areas of the home. There is a large lounge and lounge/dining area in the original part of the home. At the rear of the home, on the ground floor, are a small quiet lounge and a conservatory that can be used as a dining area. The fees for the home as provided to CSCI at the time of inspection range from £431 to £650. Additional charges include hairdressing, chiropody and newspapers. See the following website for further guidance on fees and contracts. http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_c hoos.aspx DS0000055350.V315129.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over nine hours on one day in October 2006. This was the second key inspection to be undertaken this year. A tour of the premises took place and three staff files, three residents care records and relevant documentation and policies and procedures relating to the running of the home were inspected. Eleven residents, three visitors to the home and the staff on duty were spoken with. Carolyn Jolliffe the registered manager was available throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: This report contains ten requirements covering residents care records, administration of medication and staff training. A number have been repeated from the previous inspection. DS0000055350.V315129.R02.S.doc Version 5.2 Page 6 The written pre admission assessment of residents needs does not contain sufficient detail to ensure that the Norlington has the appropriate equipment, resources and environment to meet the individual needs. Care records do not provide sufficient detail to ensure that the resident’s health and personal needs are being fully met. The home has systems in place for managing residents’ medicines but some aspects need improving to protect residents. A letter of serious concern was sent to the registered person following this inspection. Group social activities are provided in the home but these do not consistently meet the needs of the residents’ individual needs. Procedures and training are not in place to ensure residents are protected from abuse. Short falls in staff training results in some care staff not being fully competent to do their jobs properly and therefore residents could not be assured they were in safe hands at all times. The lack of a fully implemented formal quality assurance system limits the extent to which the home is able to demonstrate that it meets the expectations of service users. 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. DS0000055350.V315129.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 DS0000055350.V315129.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): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The written assessment does not contain sufficient detail to ensure that the Norlington has the appropriate equipment, resources and environment to meet the individual needs. EVIDENCE: The care file of a recently admitted resident contained an assessment that had been undertaken before the home confirmed by letter that their needs could be met. In discussion with the registered manager it was evident that a detailed assessment had taken place but the written information available was limited. There was no clear indication of how their personal care needs are met including how much they were able to achieve for themselves or the level of assistance required with mobility. Staff spoken to said that they are usually aware of what the residents need when they are admitted. DS0000055350.V315129.R02.S.doc Version 5.2 Page 9 The Norlington does not provide intermediate care therefore standard 6 is not applicable. DS0000055350.V315129.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care records do not provide sufficient detail to ensure that the resident’s health and personal needs are being fully met. The home has systems in place for managing residents’ medicines but some aspects need improving to protect residents. Staff treat residents with respect and dignity, promoting residents’ feelings of worth as valued members of the household. EVIDENCE: New recording systems have been introduced since the last inspection to make the care records easier to read and to retrieve information. Three residents care records were read and the content was variable. An activities of daily living assessment is undertaken to inform the development of a care plan. One assessment for washing and dressing states ‘needs help, can choose own clothes’ and the care plan ‘assist with all personal hygiene needs’. There is insufficient detail to inform the care worker of how the required tasks DS0000055350.V315129.R02.S.doc Version 5.2 Page 11 are to be carried out. There is no indication of the amount of input the resident needs to manage their own personal hygiene. One resident’s care records contained a clear detailed wound assessment and care plan. Wounds are monitored monthly and completed forms evidenced that issues are identified and action taken. One resident’s care records contained forms for a client handling risk assessment, continence assessment and nutritional assessment but these have not been completed. The resident had been identified as at risk of falling and the accident book recorded a fall following admission but a falls risk assessment had not been completed. The daily record identifies changes in residents needs but these are not consistently reflected in their care plan although discussion with staff demonstrated that although not documented the care is provided. A number of residents have been assessed as requiring their food and drink intake to be recorded. When visiting residents the records seen had not been consistently completed. According to one resident’s record the only fluid they had been given was one cup of tea and one cup of coffee by early afternoon. There was no jug of water available in the resident’s room. Discussion with a resident identified that they had received more fluid than had been recorded. The care plans state that pressure relieving equipment is required when appropriate but there is no further information provided to identify the actual product provided. The care records viewed included a medication care plan that has been introduced since the last inspection. While viewing the Medication Administration Records (MAR) it was identified that there were six gaps where medicines had not been signed as administered. When the relevant blister packs were checked the medicines were still in place so had not been administered. It was not possible to ascertain whether the medicine provided in a box had been given. The home has developed an audit system but on this occasion the date the box of medicine had been started was unknown. There was no documented reason why the medicines had been omitted. Following the inspection a letter of serious concern was sent to the registered person. Handwritten additions to the MAR sheets had not all been signed by two members of staff. Staff induction includes respecting residents privacy and dignity. This was confirmed when speaking with staff. Staff were seen knocking on doors and waiting for an answer before entering residents’ rooms. Residents spoken with said that they were always addressed in the way they had requested and the staff are very polite. DS0000055350.V315129.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 adequate. This judgement has been made using available evidence including a visit to this service. The social care provided in the home does not consistently satisfy the social and recreational interests and needs of the residents. The flexibility of the home enables residents to retain control over their lives where feasible and to maintain contact with their family and friends. Residents are offered a menu that provides a varied and well balanced diet. EVIDENCE: The residents’ records now include a social assessment that with further development will provide a full picture of the person’s past family, work and social history and will assist with planning for their future care. Residents meetings are held monthly and have included topics such as social activities and nutrition. Minutes are recorded and residents who have attended a meeting said that they thought them ‘a very good idea’. A monthly newsletter is produced and copies are available in the reception area. The week following the inspection has been designated Harvest Festival week and will include food tasting and a church service. DS0000055350.V315129.R02.S.doc Version 5.2 Page 13 There is a programme of group activities available and the home is working towards meeting the social needs of the residents where these activities are not appropriate. Service users receive visitors whenever they wish. A record is maintained of all visitors to the home. The home encourages friends and relatives to keep in contact. Visitors spoken with confirmed that visitors were always made welcome by the staff. One resident was looking forward to their relative visiting and others talked about their family and friends who visit. Those residents who were able to articulate a view confirmed that they were able to make choices about such matters as what they ate and when they got up in the mornings and went to bed at night. Residents are able to “personalise” their bedroom with additional items of their choice. This was confirmed when visiting residents’ bedrooms. Residents are asked in the morning for their choice of lunch and at teatime for their choice of evening meal. The menus viewed appeared well balanced and nutritious including the provision of five pieces of fruit and vegetables each day. There were adequate fresh fruit, vegetables and dry store items available. Residents are provided with breakfast, lunch, evening meal and a snack in the evening. Residents agreed that the food supplied is good. Residents who require a soft diet have their meal pureed in separate piles to aid presentation. Service users eat their meals either in the communal room or in their bedroom with several needing assistance with feeding. Residents spoken with were very positive about the quality of the meals provided. DS0000055350.V315129.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 poor. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be taken seriously and acted upon. Procedures and training are not in place to ensure residents are protected from abuse. EVIDENCE: One complaint had been received by CSCI and passed to the home to investigate and the home had received a number of complaints directly. The complaints had been well documented, investigated and action taken to address identified issues. One relative had made a complaint about the laundry and this had been fully investigated and had resulted in the introduction of the key worker system. This gives the responsibility for assisting the individual resident in maintaining their clothing to the designated key worker. The complainant was satisfied with the outcome. The home has an adult protection policy but this still needs reviewing to clearly provide the actions that would be taken if an adult protection issue were reported in line with the multi agency ‘No Secrets’ guidelines. Staff have still to receive training on the prevention of abuse. The registered manager and another member of staff are attending a training day and will then provide training for the remaining staff. DS0000055350.V315129.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing the residents with a comfortable, clean and well maintained place to live. EVIDENCE: The home is well decorated and comfortably furnished. The dining room was in the process of being redecorated at the time of inspection. The home employs a full time and a part time maintenance person. The Dorset Fire and Rescue Service last visited the home in October 2005 and the Environmental Health Office October 2004. There are no outstanding unmet recommendations from these visits. Low level lighting is now provided in all rooms and this forms part of the monthly monitoring undertaken by the home. A number of bedrooms still have fluorescent strip lighting. The resident’s preference for this type of lighting has been included in the individual care records. DS0000055350.V315129.R02.S.doc Version 5.2 Page 16 The low pressure and temperature of the hot water from the wash hand basin taps in two residents rooms and one toilet identified during the last inspection has now been rectified. This was confirmed by care staff spoken with. On the day of inspection the home was clean and no malodours were noted. All residents and visitors spoken with commented positively about the laundry service and the cleanliness of the home. Designated staff are employed to attend to the laundry and the cleaning of the home. A relative commented that the home ‘is always clean and welcoming when they visit’. All staff have received infection control training. DS0000055350.V315129.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 adequate. This judgement has been made using available evidence including a visit to this service. The levels of staffing and the skill mix meet the needs of the residents and they are protected by the systems in place for staff recruitment Short falls in staff training results in some care staff not being fully competent to do their jobs properly and therefore residents could not be assured they were in safe hands at all times. EVIDENCE: Staff rosters are maintained showing which staff are on duty at any time during the day and night. The rosters for the past three weeks evidenced that the home has been adequately staffed for the occupancy level of 32 residents including twenty requiring nursing care. In addition to care staff the Norlington employs staff to cover housekeeping, cooking, maintenance and administration. Residents spoken with agreed that staff are there when they need help and the call bell system is monitored three monthly to ensure they are being answered within an acceptable time. Two care staff have achieved a level 2 NVQ in care and six are at present undertaking the training. The home is looking at funding and was referred to the following websites www.picbdp.co.uk and www.traintogain.gov.uk to assist with this process. DS0000055350.V315129.R02.S.doc Version 5.2 Page 18 Three staff records viewed evidenced all the relevant checks and information had been obtained prior to the member of staff commencing at the home. Training records of two recently appointed members of staff contained documentation to evidence that an induction had been undertaken using the Skills for Care induction standards. The care staff have all received manual handling, infection control and health and safety training. The home has a number of residents diagnosed with dementia. Three staff have received training in dementia care and further training is planned. Training has been provided on the care of residents with Parkinson’s disease and training provided by the Stroke Association is planned. A clear individual staff training assessment and action plan will assist with planning a training programme for the home and ensure that care staff receive the training they require. DS0000055350.V315129.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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced person who is able to discharge her duties fully ensuring that residents live in a home that is well run. The lack of a fully implemented formal quality assurance system limits the extent to which the home is able to demonstrate that it meets the expectations of service users. Regular staff supervision ensures that the homes training, policies and procedures are implemented to protect the residents. Residents manage their own finances or have a representative acting on their behalf to ensure their financial interests are met. Systems are in place to promote and protect the safety and welfare of residents and staff. DS0000055350.V315129.R02.S.doc Version 5.2 Page 20 EVIDENCE: Since the last inspection the CSCI has registered Carolyn Jolliffe as the registered manager at the Norlington. The registered manager has just successfully completed the Foundation Degree in Care Home Management. Staff and residents spoken with agreed that the manager is very approachable and will listen. Staff said that there have been changes and felt that they were ‘for the better’. The home is gradually introducing a self-monitoring programme including care records, medication, accidents, complaints and infection control. Residents meetings are held and a newsletter produced monthly. A survey is to be developed to ascertain the views of the residents who are unable to attend the meetings. A system for gaining the views of residents, relatives, friends and representatives as well as stakeholders in the community such as GPs, chiropodist and hairdresser needs to be developed. This will assist with measuring the home’s success in meeting their aims and objectives. Residents either handle their own financial affairs or are assisted by family, friends or professional advisors. Pocket money is held for a number of residents and clear records are maintained. The money is kept in secure facilities. Residents confirmed that the home keep some money for them to pay for hairdressing, chiropody and anything else they may want to buy. The staff now receive an annual appraisal and regular supervision that needs more information documented relating to the areas discussed. Staff meetings have also been introduced and the minutes of the meetings are kept on file and were available to the inspector. This was confirmed by staff spoken with who generally agreed that they found supervision very ‘useful’ and ‘an opportunity to ‘talk about what is happening’. All gas installations, central heating, electrical wiring and appliances and equipment used to meet service user needs has been checked. Policies and procedures are available relating to health and safety, Control of Substances Hazardous to Health (COSHH), infection control, manual handling and first aid are in place. Fire training, drills and fire safety checks have been completed as required. An accident book is maintained and analysed monthly. An accident to a resident identified in their care records had been recorded in the accident book. DS0000055350.V315129.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 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 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 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 DS0000055350.V315129.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. The registered person must ensure that a full and detailed care assessment has been undertaken before the resident is admitted to the home. Timescale of 31/08/06 not met. The registered person shall ensure that residents care plans contain sufficient detail to provide clear guidance to staff on the actions to be taken to meet their care needs. Timescale of 31/08/06 not met. The registered person must ensure that proper provision is made for the health care and where appropriate treatment of residents. Timescale of 31/08/06 not met. The registered person must ensure that all residents receive their medication as prescribed unless the reason for omission is clearly documented. 1 OP3 14 31/01/07 2. OP7 15(1) 31/01/07 3. OP8 12(1)Sch 3 31/01/07 4. OP9 13(2)Sch 3 03/10/06 DS0000055350.V315129.R02.S.doc Version 5.2 Page 23 5. OP9 13(2) Sch 3 Staff must accurately record the administration of medicines at the time they are given. Timescale of 30/09/06 not met The registered person must consult residents about their social interests and provide facilities and resources to meet their needs. Timescale of 28/02/06 not met The registered person must produce an adult protection procedure in line with the Dorset local multi agency guidelines ‘No Secrets’. All staff must receive training on the prevention of abuse. Timescale of 31/08/06 not met The registered person must develop a plan to demonstrate how they will achieve and maintain a minimum ratio of 50 of care staff having obtained an NVQ level 2 in care or equivalent. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users• ensure that at all times suitably qualified, competent and experienced persons are working at the care home; • ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. DS0000055350.V315129.R02.S.doc 31/01/07 6. OP12 16(m)(n) 31/01/07 7. OP18 13(6) 31/01/07 8 OP28 18 31/01/07 9. OP30 18(c)(i) 31/01/07 Version 5.2 Page 24 There should be evidence that all staff have an individual training assessment and profile. Timescale of 31/08/06 not met The registered person must ensure that the home has an effective quality assurance and monitoring system. Timescale of 31/08/06 not met 10. OP33 24 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations It is a recommendation that suitably qualified persons, including a qualified occupational therapist with specialist knowledge of the client group that the home caters for, make an assessment of the premises and facilities. 1 OP22 DS0000055350.V315129.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000055350.V315129.R02.S.doc Version 5.2 Page 26 - 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. 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