CARE HOMES FOR OLDER PEOPLE
Pinewood Lodge Oxhey Drive Watford Hertfordshire WD19 7HR Lead Inspector
Neil Fernando Unannounced 07 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Pinewood Lodge Address Oxhey Drive, Watford, Hertfordshire WD19 7HR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 421 7900 0208 421 7961 Quantum Care Limited CRH PC 60 Category(ies) of DE(E) - Dementia over 65 - 60 places registration, with number OP - Old Age - 60 places of places PD(E) - Physical Disability over 65 - 60 places Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 18 November 2004 Brief Description of the Service: Pinewood Lodge is a modern design, purpose built home that was completed in 1997. It comprises a two-storey building with a main entrance to the first floor at upper ground level and a lower ground floor. Accommodation is offered in four 15 bedded units, catering for 60 older people requiring long term residential care. All sixty bedrooms are in excess of 12 sq. metres and have toilet and wash hand en-suite facilities. Each unit has a separate lounge and dining area. There is also a fully fitted kitchenette and medication storage station in this location. Other facilities available to service users include a ground floor conservatory and first floor hairdressing salon. Each unit has a communal assisted bathroom and assisted shower room. The home has a fully fitted stainless steel equipped kitchen with appropriate storage rooms and cold storage equipment and a well-equipped laundry facility. The gardens extend around the home, which is screened from the road and other residences by mature hedges and trees. There are pleasant patio areas where residents can sit out. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the first inspection for the year 2005/6 under the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. The last inspection (Unannounced) was carried out on 18.11.04. This establishment is registered to accommodate a maximum of 60 older people of both genders, who may have dementia and/or a physical disability. It is one of several care homes owned and managed by Quantum Care Limited. At the time of the inspection there were 60 service users in residence. The unannounced inspection took place on 7.07.05 between 11.05 am and 6.20 pm. A total of 12 service users, 9 staff members including the Deputy Manager and Acting Manager and 4 visiting relatives were spoken to, in order to seek their views regarding the quality of life at Pinewood Lodge. What the service does well:
The Organisation including the staff team at Pinewood Lodge continues to embrace and deliver on the National Minimum Standards for Care Homes for Older People. The main finding of the inspection is that many of the National Minimum Standards assessed on this occasion have been achieved. Overall, evidence available suggests that the quality of care for service users has been maintained to a good standard. The arrangements to enable service users and their relatives the opportunity to visit and make an informed decision about the facilities offered at Pinewood Lodge is being well managed. The assessment of needs carried out prior to any resident being offered a place remains comprehensive. There is some evidence to suggest that identified health and personal care needs are being addressed and monitored through a monthly review system, involving the resident and other significant people. Service users are treated with dignity and respect, and their right to privacy is upheld. The care staff team appear to work very hard to facilitate some social and recreational activities for service users. Evidence shows that residents enjoy a choice of well-balanced and wholesome meals. Information on making a complaint is well publicised and relatives and professionals should be capable of making a complaint, if they are dissatisfied with any aspect of the service offered to their relatives at this establishment. The protection systems including staff recruitment are adequately robust and these should ensure the safety for residents.
Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 6 Visiting relatives spoken to are most complimentary about the staff team and they are evidently very satisfied with the quality of care offered to their relatives. Overall, they spoke well of all aspects of the home. Considering the degree of mental frailty and dementia of service users accommodated at the time of the inspection, it was not possible for the Inspector to gain any accurate information from a significant number of residents. However, residents who are able to communicate verbally echoed a high level of satisfaction regarding the quality of care they receive. The environment continues to be well maintained and furnished. Health and safety issues are being attended to. The home is comfortable and service users are encouraged to make it their home, through inclusion in decisionmaking and encouragement to personalise individual rooms. A high standard of cleanliness was evident throughout. The day and night care staffing arrangements remain satisfactory. The members of the management team are supportive and should be capable of managing this establishment. Another commendable strength of the management team is their openness and willingness to cooperate and work with the Commission. What has improved since the last inspection? What they could do better:
There are four requirements (2 outstanding from the last inspection report) and three recommendations (1 outstanding from the last inspection report) arising from this report, which need addressing. It is crucial that essential training on care planning and the Protection of Vulnerable Adults is made accessible to staff members as appropriate. Monthly review notes need improving and the level of social and recreational activities for service users would hopefully improve, once the Activities Coordinator is in post. In terms of staff management systems, the domestic arrangements should be reviewed and the frequency of staff formal supervision, increased. In addition, the Registered Person must ensure that the specified documents are available on individual files for staff members, as required under
Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 7 Regulation 19 (1) (i) of The Care Homes Regulations 2001. Whilst health and safety matters are being attended to, it is required that all staff members participate in fire drills. 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. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5. The arrangements to enable residents and their relatives to make an informed choice regarding the facilities offered and suitability of the home remain satisfactory. Information available also suggests that they appreciate the opportunity to visit the home, meet with staff members and service users, and be involved in matters which affect their daily lives. EVIDENCE: The home has an up-to-date statement of purpose and a service user’s guide to the home. Evidence available indicates that a copy of the guide is made available to the service user, their representative and professionals, as appropriate. The case records for 6 service users were examined and these include comprehensive details of the completed pre-admission assessment undertaken by a member of the home management team. Information gained from 2 new service users, 4 visiting relatives and staff members including the Deputy Manager and Manager provides good evidence that the arrangements to enable service users and their relatives/friends the opportunity to visit and make an informed decision about the facilities offered
Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 10 at this establishment is satisfactory. They would spend time looking around, speaking to other service users and a meal is offered if required. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10. The care planning process requires consistency and continuity from staff members, in order to holistically reflect the identified needs/requirements of each service user. It is however positive that residents and relatives appear to pro-actively participate in the care planning and review process. Residents expressed satisfaction in the manner their personal and health care needs are being delivered to them. Observation of care practice indicates that residents are treated with respect and the right to privacy, promoted. EVIDENCE: Information gathered from staff members including the Manager, service users and 4 visiting relatives indicates that the needs of residents are being identified on an on going basis. A random sample of care plans for 13 service users were examined. Whilst some of the care plans are comprehensive others have been only partly completed. For example, the care plans did not reflect the identified health, cultural and religious needs of the service users in a significant number of cases. However, staff members have consistently recorded the care given, progress made and interactions with service users. There is good evidence to show that Monthly reviews of care plans are being carried out, but some improvement should be made, in order to reasonably reflect the changing needs and requirements for health and personal care for each service user.
Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 12 The Manager reported that the above inconsistency and shortcomings are due to the fact that some staff members have received training on care planning whilst others have not. The Commission also notes that shortfalls had been raised with respect to this subject in the last three inspection reports. Remedial action must be taken. Service users have access to District Nurses as and when needed and those who are incontinent have appropriate incontinence aids available. All service users are registered with a GP. Other professionals, residents have access to include Dentist, Optician, Podiatrist, Psychiatrist and Dietician. Consistent with the last two inspection reports, excellent evidence is available to demonstrate that service users are treated with dignity and respect, and their privacy upheld. Procedures on how to promote the privacy and dignity of service users are available and accessible to staff members. This subject is also included in staff’s induction programme, home’s statement of purpose and service user’s guide. Staff members spoken to, cited many examples of how residents’ privacy and dignity are protected and promoted at all times. The service users observed during the course of this inspection appeared to be well cared for, were comfortable and received care and attention in a timely manner. Service users, who are able to communicate verbally, echoed a high level of satisfaction regarding the manner staff members treat and respect them. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15. Service users’ interests, expectations and aspirations are being sought by staff and fulfilled to an extent. The home has a programme of social and recreational activities for its service users but given the care characteristics and dependency of service users, this really only works if is a dedicated Activities Co-ordinator in post – a view echoed by many staff members spoken to. Links with the local community and social contact with family and friends are good. All service users described the quality of food available to them as “Good”. EVIDENCE: Currently, the Activities Co-ordinator’s post is vacant and the Manager stated that a recruitment drive is in progress to fill this vacancy. The arrangements in the past have been good and once the Activities Co-ordinator is in post, the home will again have a full programme of activities, in order to maintain an adequate level of stimulation for service users. The new Activities Co-ordinator will also need to oversee the support that care staff members provide in this area. In the meantime, care staff members are doing their best to facilitate some activities for residents. Although this standard is not fully met, it is the Commission’s view that making a requirement is unnecessary, given the proactive stance taken by the Organisation to fill this very crucial position. Evidence shows that residents are proactively encouraged to maintain social contact with family and friends. Service users can receive their visitors in
Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 14 private and there are no strict visiting times. There were several visitors during the inspection, which is a normal occurrence. The views of those spoken to are most complimentary about the staff team and they are evidently very satisfied with the quality of care offered to their relatives. Overall, they spoke well of all aspects of the home. Information gained indicates that residents are offered a varied, wholesome and nutritious diet, which is suited to individual needs/requirements. Meals are taken in congenial setting and at flexible times. Lunch was observed to be unhurried with residents being given sufficient time to eat. The atmosphere in the dining rooms was relaxed and care practice observed was good. Service users were consistent in their views that the variety and quality of food offered to them is of a good standard. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The complaint procedures are well advertised and relatives and significant others should be able to make a complaint. Equally, systems in operation should offer adequate protection to service users from harm. Once all staff members receive essential training on the Protection of Vulnerable Adults, this would reinforce the existing systems and would further ensure the safety of service users. EVIDENCE: Staff members interviewed including the Deputy Manager demonstrated an understanding of the procedures and their responsibilities towards ensuring that any complaint is dealt with speedily and satisfactorily. Information is available to service users, relatives and professionals on how to make a complaint and how the home intends to deal with it. Given the mental frailty and dementia of the service users, it has not been possible to gain any accurate information on their views and experience on the subject. However, information gathered from four visiting relatives suggests that they would be able to make a complaint if they were dissatisfied with any aspect of the service offered to their relatives. The home has not received any complaint since the last inspection in November 2004. The overall impression gained is that complaints would be dealt with satisfactorily. The whistle blowing policy is available and accessible to the staff team. The home also had procedures on the protection of vulnerable adults. Discussion on the procedures is part of the induction for all new staff members and this subject is also included in the NVQ assessment for those members undertaking this course. Training for staff on the Protection of Vulnerable Adults has been identified for sometime and the previous Manager had reported that this is a
Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 16 matter the Organisation would address as a priority, in the very near future. This matter has however remained outstanding since August 2004. Essential training on the protection of vulnerable adults must be made accessible to staff members, in order to improve their knowledge and skills, and effectively deal with any protection issue arising. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26. Pinewood Lodge continues to provide very good living conditions and is satisfactory for the individual and collective needs of the service users. The organisation of the establishment in units appears to generate a warm and domestic atmosphere and promotes a more individual approach to service users needs. The standard of cleanliness was exceptionally high and residents appear to appreciate and enjoy their physical environment. EVIDENCE: Pinewood Lodge is a modern design, purpose built two-storey residential care home registered in December 1997. The communal areas and bedrooms are decorated and furnished in a style to reflect the period features of the building. A programme of routine maintenance is in place and ongoing. All areas viewed are accessible and safe, and decorated, maintained, and furnished to high standard. In the main, the physical environment has been maintained to a high standard. Consistent with the last inspection report, there continues to be a high standard of housekeeping throughout those areas viewed during this visit. Given the level of incontinency with the current residents, there were no malPinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 18 odours present – an observation also reported by the 4 visiting relatives spoken with. This is quite an achievement and the domestic staff team are to be commended for their hard work and achievement. Staff members have access to gloves and aprons as appropriate. The management of domestic, clinical waste and soiled laundry is consistently in line with safe working practices and staff members are aware of the risks of cross infection and take the issues seriously. There were no health hazards noted. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. The establishment continues to provide the staffing levels required by day and night, which demonstrates that residents’ needs are being responded to satisfactorily. The recruitment process for staff remains robust hence promoting a higher degree of protection for vulnerable service users. The training needs of the staff team including NVQ assessment are being given a high profile and this will, no doubt, ensure delivery of effective and good quality care for service users. EVIDENCE: The staffing details provided by the Deputy Manager and Manager, and information gained from duty rotas for the period between 18.06.05 and 15.07.05 indicates the following: a minimum of 11 care staff members plus 1 senior are provided in the morning and afternoon shifts. There is a minimum of 4 care staff members including a senior available on waking duty each night. The staff members on duty also reconciled with the rotas for the day. The Deputy Manager and Manager’s times are supernumerary and their times have not been included in the staffing calculation. The Manager stated that staffing levels are reviewed regularly to meet the changing needs of the residents’ group. The care staffing levels are deemed to be adequate. There are sufficient ancillary members in dedicated roles for catering, laundry and housekeeping. It would however be helpful to review the domestic arrangements, in order to ensure that there is at least some input between 12 pm and 5 pm daily. The Commission acknowledges that whilst the overall domestic input remains satisfactory in terms of numbers and hours, the
Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 20 distribution during the above periods needs attention. And therefore, although the standard is met, a recommendation has been made. Information available indicates that staff members have received mandatory training to assist them to do their work competently. There are 14 members of care staff who have completed their NVQ Level 2 assessment (45.1 ) to date. A further 13 members are currently undertaking the same assessment. Assuming that all these workers successfully complete their assessment and none of them leave their post, the home should achieve a ratio of 87 , which would be a significant achievement by the home. The home follows the Organisation’s procedures for the recruitment and selection of staff members. Good evidence is available to indicate that the Manager has made a concerted effort to ensure that all new recruits are subject to in depth checks, prior to them starting work at Pinewood Lodge. An interview with the applicant, obtaining two written references and other required checks including CRB are part of the process. The personnel recruitment files for 7 staff including the most recently appointed members were scrutinised. Minor improvement is required to reflect the documents stated in Schedule 2 and 4 of The Care Homes Regulations 2001. For example, a copy of Birth Certificate or passport and a current photo was not available. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36 and 38. There are a number of care and staff management systems including health and safety, which are being implemented to good effect. The safety of service users and staff are being protected, and their welfare promoted. The home is a safe place for service users to live in – a view shared by staff members and visiting relatives spoken to. Records viewed are maintained as required by Regulations. EVIDENCE: The Registered Manager was transferred on 20.06.05 to another establishment within the Organisation. There is an Acting Manager who is currently managing the home and she is supported by the very able Deputy Manager. The Manager appears to have the necessary experience and the interim management arrangements appear to be satisfactory. A recruitment drive is in progress with a view to fill the Registered Manager’s vacant post. The management systems are transparent and service users and staff members confirmed that the Management team are very supportive. Observation of
Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 22 care practice during the visit also demonstrates that members of staff and service users enjoy a very good relationship. Information gathered from staff members including members of the management team shows that arrangements are in place for staff members to receive formal one to one supervision. Details of supervision sessions are recorded. The frequency of supervision should be increased to once every two months, at minimum. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x
COMPLAINTS AND PROTECTION 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x x x x 2 x 2 Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 24 YES 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 OP7 Regulation 18 (1) (a) & (c) (i) Requirement Timescale for action 7.10.05 2. OP19 18 (1) (a) & (c) (i) 3. OP29 17 (2) & 19 (1) (b) (i) 23 (4) (e) 4. OP38 The registered person must ensure that care staff members receive essential training on Care Planning. (Previous requirement, partly achieved). The registered person must 15.11.05 ensure that care staff members receive essential training on the Protection of Vulnerable Adults. (Previous requirement). The registered person must 15.09.05 ensure that specified documents in Schedule 2 and 4 are maintained for all new staff. The registered person must 15.09.05 ensure that all staff members participate in fire drills RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP27 Good Practice Recommendations Monthly review notes should be in greater detail, in order to reasonably reflect the changing needs and requirements of each service user. (Previous recommendation). Review the domestic arrangements, in order to ensure that
I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 25 Pinewood Lodge 3. OP36 there is at least some input between 12 pm and 5 pm daily. The frequency of staff formal supervision should be increased to once every 2 months, at minimum. Pinewood Lodge I52-I02 s19496 Pinewood Lodge v237299 070705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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