Inspection on 25/04/06 for Norton Lees Hall

This inspection was carried out on 25th April 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

Norton Lees Hall 17/04/07

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Hawkhills

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The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Norton Lees Hall 156 Warminster Road Norton Lees Sheffield South Yorkshire S8 8PQ Lead Inspector Michael O`Neil Key Unannounced Inspection 25th April 2006 09:10 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 Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Norton Lees Hall Address 156 Warminster Road Norton Lees Sheffield South Yorkshire S8 8PQ 0845 6027470 0114 2589731 nortonleeshall@tri-care.co.uk None Orchard Care Homes.Com Ltd 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) Mrs Diane Lesley Whitehead Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection Brief Description of the Service: Norton Lees Hall is situated in the Norton Lees area of Sheffield close to local shops, other amenities and a bus route. The building is purpose built and has two floors accommodating service users who require personal care. The home is registered for 40 places. The home has a sufficient number of baths, toilets and showers. All the bedrooms are single and have en-suite toilets. The home is accessible to service users, ramps and a lift are available, and aids and adaptations are in place. The home has a pleasant enclosed garden. Car parking is available. The manager confirmed that from 27.03.06 the weekly range of fees charged for accommodation and care varied from £430-£460. Additional charges were made for services such as chiropody and hairdressing. A statement of purpose and service user guide were available for residents in all the bedrooms of the home and in the foyer. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Mike O’Neil, regulation inspector. This inspection took place between the hours of 9.10 am and 4:40 pm. Diane Whitehead, registered manager was present during the inspection. The manager submitted a pre inspection questionnaire and 8 residents returned care home surveys to the CSCI prior to the actual visit to the home. The residents’ views and some information from the questionnaire is included in the main body of the report. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to 6 staff, 5 relatives and 8 residents. The inspector wishes to thank the staff, relatives and residents for their time, friendliness and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Some care plans must be improved to ensure that staff are able to know what to do for each resident. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 6 Satisfactory hygiene and control of infection standards must be maintained in the laundry. Hand washing and protective clothing had not been provided. Numbers of staff must be maintained as agreed with the CSCI. New staff need to receive adequate training when they start work at the home. The recruitment information obtained for new staff needs to be improved. Improvements are needed on fire safety measures. More care is needed so that substances hazardous to health are safely stored. 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. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 is not applicable to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives had the information they needed to make an informed choice about where they lived. No resident moves into the home without having his or her needs assessed which ensures that care needs can be met. This home does not provide intermediate care services. EVIDENCE: A statement of purpose and service user guide were available for all residents or their relatives. Residents were able to show the inspector the folders in their rooms that contained this information. The manager confirmed that residents were only admitted to the home once they were sure that they could meet their needs. Copies of full needs assessments were in the residents files. All the relevant information from the assessments had been built into the care plan. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ health, social and personal care needs were generally well documented in the care plans; however, inadequacies in the documentation meant that the resident’s needs could not be fully met. A range of health care professionals visited the home to assist in maintaining the health care needs of residents. Residents themselves said that the care they were receiving was very good and that the staff were very nice. Relatives said that the care delivered by staff was satisfactory or excellent. Medication storage presented a risk to the residents’ health and welfare. Residents said that the staff promoted their privacy and dignity. EVIDENCE: Three resident plans of care were checked. The plans checked set out individual needs and the action required by staff to ensure those needs were met. The care plans identified that a range of health professionals visited the home to assist in maintaining the residents health care needs. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 10 The care plans however were not adequate as • • • • Residents or their relatives were not involved in drawing up or reviewing the care plans. A nutritional risk assessment was not fully completed and suggested that the resident did not have any problems with nutrition when in actual fact there was a problem. Staff, when writing the residents daily notes, were not being reflective of the information actually recorded in the residents care plan. The daily notes of the residents were stored in a different file to that of the residents care plan. So that staff could easily record information in the daily notes a “mini type care plan” had been developed and placed in the daily note folder. The inspector found that the care plans held in the “daily note” and actual “care plan” files differed. This practice meant that the resident could not receive consistent continuity of care. All the residents interviewed and via questionnaires submitted to the CSCI said they were “satisfied” or “very happy” with the care they received at Norton Lees Hall. All the relatives interviewed said they were “satisfied” with the care provided by the staff of Norton Lees Hall. Residents said that they were happy and that the staff were “champion” or “very nice”. The inspector observed that the residents of Norton Lees Hall were well dressed in clean clothes and had received a good standard of personal care. Resident’s nails were clean, male service users had been assisted to shave and all residents were appropriately dressed. The fridge in the treatment room, which is used to store some medication, was not working properly. This could present a risk to the residents’ health and welfare, as the medication was not stored at the correct temperature. Residents said that staff at the home respected their privacy and dignity by knocking on their doors and waiting for a response before entering. The inspector saw and heard staff speaking to residents in a respectful way and saw staff hand the residents their post unopened. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had a choice of lifestyle within the home and they were able to maintain contact with family and friends ensuring that they continue to be involved in community life. Meals served at the home were of a good quality and offered choice. EVIDENCE: Residents were able to spend their day as they wished and move freely around the home. Relatives said that they were always made to feel welcome when they visited and they were able to visit at any reasonable time of the day or evening. A friendly and welcoming feel was evident in Norton Lees Hall. Residents said they enjoyed the activities available at the home. These activities were advertised around the home. Activities were occurring during this inspection. Residents said they chose when they got up and went to bed and generally how they spent their day. Some residents said they preferred to stay in their room at certain times of the day and that the staff respected their decision. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 12 Residents said that they had a choice of food, up to 4 options at lunchtime, and that the quality of food served was good. Lunch was served in a pleasant relaxed manner and residents were sat at tables, which had been nicely set. Residents said that they enjoyed their lunch. Fresh fruit was available in the lounges of the home and residents said that drinks and snacks were available at all times. The cook was aware of residents’ special diets and said she used fresh produce in the majority of the dishes prepared. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 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 the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure residents are protected from abuse. Complaints procedures are in place to enable residents and relatives to feel confident that any concerns they voice will be listened to. EVIDENCE: Complaints procedures were displayed around the home. Relatives and residents said that if they had any concerns that they would feel comfortable in talking to the staff or the manager. Staff had received information on adult abuse and some staff had received formal training. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 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 the following standard(s): Standards 19, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment within the home was well maintained and clean providing a comfortable, safe environment for residents. However hygiene procedures in the laundry did not protect the staff and residents’ health and welfare. EVIDENCE: The grounds around the home were very welcoming and residents said that they were “looking forward to using the gardens when the better weather arrives”. All areas of the home were clean and tidy. Three bedrooms were checked in detail and many others seen, all were comfortable and homely. Residents said their beds were comfortable. Bed linen checked was clean and in a good condition. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 15 The home was clean, with no unpleasant odours noticeable. Relatives and residents said that staff always kept the bedrooms and home clean. A staff member said that they had received conflicting advice and had no clear guidance or policy as to the temperature that soiled linen must be washed at. No soap, paper towels or plastic aprons were available in the laundry. The manager, when made aware of this, did provide a soap dispenser and plastic aprons. These inadequacies increased the risk of cross infection Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 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 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): Standards 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Insufficient staff were provided to meet the needs of the residents. The recruitment information obtained for new staff was insufficient to adequately protect the welfare of residents who lived at the home. Staff were not receiving adequate training on their induction, so may not have the required skills to meet the residents needs. However a proportion of staff have completed training that ensures these staff have the competences to meet the residents needs. EVIDENCE: The staff rota identified agreed minimum care staffing levels were rostered to work on each shift. However after interviewing different disciplines of staff and interviewing some relatives the inspector was informed that care staff were actually undertaking non-direct care duties. Staff said that a member of care staff had to wash pots in the kitchen between 5pm and 6.30 pm as the catering staff “went home at 5pm”. Also staff have to carry out laundry duties as a laundry assistant is only employed for 3 days a week. The manager did confirm that staff were undertaking these duties. The manager, via the pre inspection questionnaire submitted to the CSCI prior to inspection stated that the required 50 of care staff had not achieved their Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 17 level 2/3 NVQ qualification, although the manager said a number of staff had enrolled or were undertaking their NVQ training. Two staff files were checked. The recruitment information obtained for one new member of staff was insufficient to adequately protect the welfare of residents who lived at the home. The file did not contain a reference from the employee’s last employer, an application form, an employment history or information to verify identity. Both files did however include an enhanced Criminal Record Bureau (CRB) and Protection Of Vulnerable Adults (POVA) check. The manager did say that some of the information was held at Head office in Leeds, however the regulations do state that the information above must be “at all times available for inspection in the care home” The manager confirmed that all staff working at the home had completed enhanced CRB/POVA checks. There was a training and development plan for the staff. Staff said they were encouraged to attend training on various care topics but in recent months this training was on an adhoc basis. Staff interviewed said that when they started work they did not receive induction training in the first two months of their employment. A staff file checked identified that a member of staff had not received adequate or in depth induction training when they commenced work at Norton Lees Hall, only basic health and safety training was provided. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 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 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): Standards 31,32,33,34,35,36,37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents did not fully benefit from the ethos, leadership and management approach of the home. This could affect the quality of the service the residents receive. The homes policies and procedures did not protect the health, safety and welfare of residents and staff. EVIDENCE: The manager said she had not started her level 4 NVQ management qualification yet. The manager was very positive about the inspection process and was committed to improve the service of Norton Lees Hall and meet the National Minimum Standards and Care Home Regulations. The residents, relatives and Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 19 staff were generally very positive about her leadership skills and approachability. Residents said that they met regularly with the manager and spoke positively about her approachability and helpfulness. Some staff however were very negative about the senior management of the home and said they felt “unsupported”. There is a quality assurance system, however the audit tool only been completed in part on an adhoc basis over the last 4 months. The manager had recently sent out questionnaires to the relatives and residents to ask for their views of the home unfortunately these questionnaires were returned to head office and the staff of the home had not received any feedback as to the views of the residents and relatives The responsible individual visited the home on a regular basis, a report was written following the visits. A copy of the responsible individuals monthly report has always been sent to the local office of the CSCI. Resident meetings took place at the home, however relatives said they had not been involved in any meetings with the management of the home. The manager confirmed the home has insurance cover is in place. An up to date insurance certificate was displayed in the foyer of the home. The manager handles money on behalf of some residents. Account sheets were kept, receipts were seen for all transactions and a second individual witnessed all transactions. Staff said they were not receiving supervision on a regular basis, which was confirmed by the manager. Records were securely stored around the home, which protected the residents’ best interests and confidentiality. The health and welfare of residents could not be fully protected, as • A visiting fire officer expressed concern that the home did not have a fire risk assessment in place. • Practice fire drills had been conducted in the home, however the records did not identify the length of the drill and the drills were not conducted at different times of the day. • Some fire doors did not fit flushly on their door rebate. • Control of substances hazardous to health (COSHH) regulations and information on hazardous products were not displayed in the laundry room where hazardous products were stored. A member of staff working in the laundry had not received COSHH training. • Requirements made by an Environmental Health Officer on a visit to the home on 3rd March 2006 had not all been met by the home. The manager did say that progress had been made to meet the requirements. • Hazardous cleaning products were stored in unlocked cupboards in the homes kitchenettes. An immediate instruction to store these products safely was issued. The cleaning products were removed and locked away within 10 minutes of the requirement being issued. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 20 Accident records were checked. The records did not contain a management review or analysis, which may identify whether accidents were occurring at similar times and involving the same residents. The manager was unclear regarding the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1985 and said she needed further information about this legal requirement. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire and food safety. Two staff records checked confirmed that this training had occurred. Fire records stated that weekly testing of the fire alarm system had occurred. A sample of records showed servicing of the homes utility systems had occurred. At the time of inspection fire exits were clear and window restraints were in situ at first floor windows checked to prevent falls. This will promote the safety and welfare of the service users. Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 3 3 2 3 1 Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP7 Regulation 15 15 Requirement Nutritional risk assessments must be up to date and complete. The residents daily notes must reflect the information actually recorded in the residents care plan. Only one care plan for each of the residents identified needs must be in use. Documentation must be available to show that residents and/or their relatives have been involved in the drawing up and evaluation of the residents care plan. The fridge in the treatment room must be repaired to ensure that medication is stored at a safe temperature. Satisfactory hygiene and control of infection standards must be maintained in the laundry. (Hand washing, protective clothing and safe washing of soiled linen) There must be sufficient numbers of competent and experienced staff on duty at all times. DS0000065376.V290886.R01.S.doc Timescale for action 01/06/06 01/06/06 3 4 OP7 OP7 15 15 01/06/06 01/08/06 5 OP9 13 01/06/06 6 OP26 16 01/06/06 7 OP27 18 01/06/06 Norton Lees Hall Version 5.1 Page 23 8 9 OP28 OP29 18 19 10 11 12 OP30 OP31 OP32 19 9,18 24 26 13 OP33 24 14 OP36 18 15 OP38 23 16 17 18 OP38 OP38 OP38 23 23 13 19 OP38 16 50 of care staff must be trained to NVQ level 2 or equivalent. The home must obtain all relevant information and documents before new employees commence work. Staff must receive induction training within 6 weeks of appointment to their posts. The manager must be trained to NVQ level 4 or equivalent in management. Residents must benefit from the ethos, leadership and management approach of the home. Systems must be implemented and maintained to review and improve the quality of care and services at the home. Formal staff supervision must occur at least six times a year. This supervision must be documented. Fire Drills must be conducted at different times of the day/night so as to ensure that all staff working at the home are aware of the procedures to follow in the event of fire.Fire Drills records must indicate the duration of the drill. Fire doors must be maintained to ensure that they can contain fire and smoke. A fire risk assessment must be in place at the home. Staff must receive COSHH training and the home must comply with the COSHH regulations 1988. Requirements made by the Environmental Health Officer during the inspection on 3rd March 2006 must be met. 31/12/06 01/06/06 01/08/06 31/12/06 01/06/06 01/07/06 01/07/06 01/07/06 01/05/06 01/05/06 01/05/06 01/06/06 Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 24 20 OP38 13 21 22 OP38 OP38 13,17 12,13,17 Substances that are hazardous to the service users health and safety must be safely stored. (Addressed at the time of Inspection) The manager must audit accident records. The manager must be aware of, and report all occurrences as required under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1985. 25/04/06 01/07/06 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Norton Lees Hall DS0000065376.V290886.R01.S.doc Version 5.1 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. 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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