Inspection on 26/01/06 for Pollard House

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Pollard House 21/06/07

Pollard House 16/01/07

Pollard House 13/06/06

Pollard House 24/08/05

Pollard House 31/08/04

Pollard House 20/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

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 Pollard House 68 Pollard Lane Undercliffe Bradford West Yorkshire BD2 4RW Lead Inspector Mary Bentley Unannounced Inspection 26th January 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 Pollard House DS0000056120.V279133.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. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pollard House Address 68 Pollard Lane Undercliffe Bradford West Yorkshire BD2 4RW 01274 636208 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Chander Shekher Kainth Mr Sohan Lal Kainth Care Home 28 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (2) Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th August 2005 Brief Description of the Service: Pollard House is an adapted Victorian building providing personal care for twenty-eight service users. The home offers care to people over the age of 65 and has 10 places registered for the care of people with dementia. There is a lounge on the lower ground floor, which is a designated smoking area for residents. There are two lounges and a dining room on the ground floor. There are bathrooms, assisted showers and toilets on each floor near to lounges and bedrooms. There is a small garden at the front the building. The home is situated on a bus route and is approximately one mile from Bradford city centre. There is limited car parking at the rear of the building with additional roadside parking. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year, from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second inspection of this home and it was unannounced; the first inspection was also unannounced and took place in August 2005. One inspector carried out the inspection between 10.00am and 5.00pm accompanied by a member of the administrative staff from the CSCI Rodley office. There have not been any additional visits to the home since August 2005. The methods used during the inspection included talking to residents, staff and management. We looked at care records and carried out a tour of the home. The home prefers the term “resident” to “service user” therefore that is the term that will be used throughout this report. Comment cards were left at the home for residents and relatives; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are discussed with the provider without revealing the identity of those completing them. What the service does well: What has improved since the last inspection? Following the last inspection thirteen requirements were made, nine of these are still outstanding and have been carried forward. A further sixteen requirements were identified from this inspection. The manager said the lack of progress was due to the fact that she was busy completing the Registered Managers Award. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pollard House DS0000056120.V279133.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 Pollard House DS0000056120.V279133.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): 2&5 The terms and conditions do not make it clear exactly what services are included in the fees. Residents admitted in emergencies or for short stays are not given copies of the terms and conditions. EVIDENCE: The home has had one admission since the last inspection; a pre-admission assessment was not done because it was an emergency admission. A copy of the assessment done by Social Services was available in the file. The manager said that the resident had not been given terms and conditions of residency because it was expected to be a short stay. She said the home does not usually give terms and conditions to short stay residents. The admission took place in September; the resident has not yet been given a copy of the Terms and Conditions. The question of whether or not the home provided televisions in bedrooms was discussed at the last inspection, as it was not clear from the Terms and Conditions. Despite the fact that the manager said the document had been Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 9 revised the situation is still not clear as the Terms and Conditions say televisions “may” be provided on request. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 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&9 The personal care needs of residents are met. The care records do not show how social care needs of residents will be dealt with and do not always provide evidence of consultation with residents and/or their representatives. Residents are not protected by the home’s systems for dealing with medicines. EVIDENCE: The care records showed how the personal and health care needs of residents would be dealt with. The home works closely with District Nursing staff to make sure that health care needs are met and this was reflected in the care records seen. There was little or no information about social care in the plans seen. There was no evidence of involvement by residents and/or their families in the plans seen. There were risk assessments about moving & handling, falls, pressure area care, continence and nutrition. Weights were recorded. There were general risk assessments but these did not always have enough detail, for example one did not address the risk of a resident smoking in their bedroom. The records showed that residents have chiropody and eye tests as needed. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 11 Generally residents looked well cared for and were satisfied that their personal care needs were met. A packet of tablets was found in a cupboard in the kitchen, they had been removed from the original package in which they were dispensed and it was not clear whom they belonged to or why they were in the kitchen cupboard. We were told they belonged to a resident and had been left out so that the night staff could give them if they were needed. Day staff take the medicine keys home with them because there is no one on night duty trained to give medicines. This is not acceptable, it is not safe practice and it also means that any residents who need night medication have to have it before the day staff leave at 8.00pm. These tablets were not recorded on the resident’s current medicine chart and there was no record of when they had been given. One member of staff was seen dispensing medicine from the container into her hand; this is not good practice, when asked about medicine pots she said they were in the kitchen. An immediate requirement notice was issued regarding medication procedures. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 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, 14 & 15 For most of the residents living in the home there is little or no opportunity to take part in social and recreational activities. The opportunities for less able residents to exercise choice and control over their lives are limited. Residents have little control over what they are given to eat and there is not enough attention given to the presentation of food. EVIDENCE: Throughout the day the televisions were on in all three communal areas. There was no evidence of residents being provided with opportunities to take part in social activities. Residents said there was nothing much to do and some said they were bored. There was no information in the care records about social activities and there was no programme of activities on display. Following the last inspection the home introduced an individual activities record for each resident. There was very little recorded after the Christmas party which took place on December 21st 2005 and the records that were available showed that most activities involved people having visitors or going out with family and/or friends. The manager said an activities organiser had been recruited but had left after two months and she had not been able to find a replacement. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 13 A small number of residents are very independent and enjoy a good quality of life. However the majority are not given the opportunities or support they need to take part in social or recreational activities. This is particularly important as a number of residents have dementia. The staff are, for the most part kind and well meaning, but have not been given the training they need to understand and meet the needs of the people they are caring for. The comments made by residents about the food varied, some said it was good. One resident said parts of the meal were often cold, on the day of the inspection they said some of vegetables were “stone cold” and not fit to eat. The problem of cold food was raised at the last inspection. Menus are displayed in the dining room but residents said we should not take any notice of them because the meals that were served did not follow the menu. There is one main course offered at lunchtime, residents said if they didn’t like it they just left it or had sandwiches. The evening cook said she would cook whatever people wanted at tea time, the food records showed that a hot meal if offered most evenings. However residents did not seem to be aware of this and said that that if they didn’t want the hot meal they were usually offered sandwiches Some meals were served to residents in their rooms at lunchtime; food covers were not used when food was being taken around the home. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 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): Residents are not confident that their complaints will be listened to, acted upon and taken seriously. The lack of staff training on adult abuse and protection creates the opportunity for residents to be put at risk. EVIDENCE: The home has a complaints procedure. However one resident had some concerns about a member of staff and did not feel confident enough to share this person’s name or to discuss it with the home manager. Only two members of staff have attended training on abuse and the protection of vulnerable adults. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 25 & 26 With the exception of the communal areas on the ground floor the standards of décor, cleanliness and maintenance were poor. There were unpleasant odours in a number of bedrooms. There are concerns about the safety of the environment. EVIDENCE: The ground floor lounges and dining room are nicely decorated. The plastic covers on the dining room tables detract from what would otherwise be a homely environment. The back lounge and the dining room overlook a golf course and provide a nice view for residents. A new floor covering has been fitted in the dining room and this is starting to lift across the middle seam, this creates a potential trip hazard for residents. The lounge on the lower ground floor that is the designated smoking area for residents was being used to store bags of old clothing and several Zimmer Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 16 frames. There was also a clothes rail with several items of clothing in this room. One bedroom has been redecorated since the last inspection unfortunately the colour scheme chosen did not brighten up the room, which has poor natural lighting. Other than that there was very little evidence of an ongoing programme of maintenance or decoration. The carpets in several bedrooms needed to be thoroughly cleaned or replaced, in one room the carpet was so dirty it was sticky to walk on and in another room the carpet was damaged by cigarette burns. There was a risk assessment relating to the fact that this resident smoked but it made no reference to the fact that the resident smoked in their bedroom which is arguably the greatest area of risk. In other parts of the home we saw broken shelves, broken lights, a damaged bed base, masking tape stuck on windows, a rusty “stand on” scales and a rusty toilet frame. There were unpleasant odours in some rooms, one of these had been identified at the last inspection and was no better on this occasion. Many of the commodes were in a poor condition. Mattresses had been left on the corridor on the top floor and there were ladders and wood in the stair well. There were no bins in most of the bedrooms. Many of the pillows were lumpy. Many electrical items did not have a portable appliance test label on them. The manager said a firm comes in once a year to do portable appliance testing and the records of this were seen. It was not clear what system there is in place to deal with electrical items that are brought into the home between these annual tests. The fire exit door on the first floor does not have an alarm fitted, this door opens onto a steep metal fire stairs and without the alarm staff have no way of knowing if residents have gone out of this door. As the home is registered to care for people with dementia, who may be likely to wander, this presents a potential risk to residents. The passenger lift and stair lifts were due to serviced in January, the manager was asked to follow this up to make sure it was done. Records were not available to show when the bath hoists and portable hoists had been serviced, this type of equipment should be serviced every six months. From the records available in the home it was not clear if the valves fitted to control hot water temperatures were working properly, that is maintaining the temperature at hot water outlets as close to 430 C as possible. There was no bath thermometer available in the home therefore we were unable to check the water temperatures. The absence of a bath thermometer shows that staff are not routinely checking the temperatures of bath water and this puts residents at risk from scalding. An immediate requirement notice was issued about this. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 17 Although cleaning cloths were colour coded, the system in use did not conform to the colour coding system recommended by Environmental Health. Staff said they used gloves and aprons when helping residents with toileting. Waste was disposed of properly. New laundry equipment has been fitted since the last inspection; the washing machines have sluice cycles, which will help with the control of infection. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 18 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 There are not always enough staff to meet residents needs. Staff are not given enough training to help them understand and meet residents needs or to help them develop their skills and knowledge. The home’s recruitment procedures are not robust enough to make sure that residents are protected. EVIDENCE: The hours worked by the acting manager and deputy manager are not shown on the duty rosters and as they did not sign in or out for duty there is no way of knowing what hours they work. There are two members of staff on duty between 5.00pm and 8.00pm, taking account of the needs of residents and the layout of the building, which has four floors; this is not enough to meet residents’ needs. The manager said there used to be another member of staff on duty during these hours but they had left. An immediate requirement notice was issued regarding staffing. Residents said most of the staff were kind and caring but there was one person who was not always and residents kept out of this person’s way, the resident was not prepared to say whom this was. The manager was informed and advised to monitor closely how staff are interacting with residents. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 19 The home has 25 of the care staff team trained to NVQ (National Vocational Qualification) level 2 or above, this has not changed since the last inspection. Two staff are doing NVQ level 3, one of these already has level 2. The manager said more staff would be enrolled for NVQ training when places became available but did not know when this would be. Other than some mandatory training there has been very little progress made with staff training since the last inspection. There was no record of induction training for newly appointed staff. The manager said she had the new Skills for Care induction standards and was planning to go through these with all the staff. The files of three recently appointed members of staff were looked at. Although the files all had two written references there were concerns about the quality of these references. None of the files had references from previous employers and in at least one case it was not clear what the connection was between the member of staff and the person who had supplied the reference. One of the staff had a criminal conviction and there was no information to explain why the home had made the decision to offer employment in spite of this. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 20 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, 32, 33, 36, 37 & 38 Taking into consideration the number of issues identified during this inspection and the seriousness of some of those issues it is not possible to say that the home is run in the best interests of residents. EVIDENCE: The Acting Manager has now successfully completed the Registered Manager Award and has made application to be registered by CSCI The manager said the owner makes regular visits to the home but there were no records of these visits and none have been sent to the CSCI. The manager said some questionnaires had been sent out to relatives but had not been returned, she did not know whom they had been sent to. The home does not have residents meetings. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 21 There was one record of staff supervision dated April 2004, the manager said others had been done but the records had been put in her portfolio for the RM award. The training records showed that moving & handling training was up to date. The manager said there had been no fire training since December 2004, one member of staff spoken to did not know what to do if the fire alarm went off, she said she had never had any fire training. All staff should have fire training at least twice a year. The records showed fire drills had taken place in November and May 2005, the manager said she thought there had been one in July 05 but there was no record. Three staff have been trained in First Aid and two staff have done Food Hygiene training. The manager said four staff were booked to do infection control training. There were a number of concerns about health and safety as detailed in the environment section of this report. Accident records should be stored in individual files to comply with Data Protection law. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 22 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 2 X X 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 2 X 2 X 2 1 2 STAFFING Standard No Score 27 1 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X X 1 1 1 Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 23 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. No. 1 Standard OP2 Regulation 5 Requirement Timescale for action 24/03/06 2 OP2 5 3 OP7 15 4 OP9 13 & 17 The terms and conditions must set out clearly what services and facilities are provided and whether or not these are included in the fees. Previous timescale of 30/11/05 not met. Every service user must be given 24/03/06 a copy of the Service Users Guide, which must include the Terms and Conditions of residency. The service users plans must set 28/04/06 out in detail how personal, health and social care needs will be met. Previous timescale of 28/10/05 not met. The registered persons must 26/01/06 make sure that medicines are stored and administered safely and that the required records are kept. The registered person must make sure that there is always a member of staff on duty who has undertaken accredited training in the management of medicines. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 24 5 OP9 6 OP12 7 OP15 8 9 OP18 OP19 10 OP19 11 OP19 12 OP22 13 14 15 OP25 OP25 OP26 CSA The registered persons must Section 31 investigate the medicine discrepancies and provide the CSCI with a copy of the investigation report. 16(2) The registered persons must consult with service users about the programme of activities and provide facilities for recreation. Previous timescale of 28/10/05 not met. 16(2) The registered persons must make sure that residents are given varied and nutritious meals and that food is served at the correct temperature. 13(6) All staff must receive training on Adult Protection and abuse. 23(2)(b) All areas of the home must be & (d) kept in a good state of repair. Furnishings and decoration must be maintained to a reasonable standard. Previous timescale of 30/11/05 not met. 13(4) An audible alarm must be fitted to the fire exit door on the first floor identified during the inspection. 23 The registered persons must make sure that a programme of maintenance and refurbishment is implemented and records kept. 13(5) The registered persons must make sure that hoists and lifts are serviced at the specified intervals. Copies of the maintenance and service records must be available for inspection. 13(4) The home must check the hot water temperatures and keep records of these checks. 13(4) A bath thermometer must be provided and staff must be trained on its use. 16(2) All parts of the home must be kept free of offensive smells. DS0000056120.V279133.R01.S.doc 24/02/06 24/03/06 24/03/06 24/03/06 26/05/06 26/05/06 28/04/06 24/03/06 26/01/06 26/01/06 24/02/06 Page 25 Pollard House Version 5.1 16 OP27 18 17 OP29 19 Previous timescale of 28/10/05 not met. The registered persons must make sure that there are enough staff on duty to meet the needs of residents at all time. New staff must not start work in the home until all the required pre-employment checks have been competed. Previous timescales of 31/12/04 & 21/09/05 not met. Staff must be given the training they need to meet the needs of residents and records of all training, including induction, must be maintained. The owner must carry out visits in accordance with the requirements of this regulation and provide copies of the reports of these visits to the CSCI. Previous timescale of 30/09/05 not met. The registered persons must implement and maintain a quality assurance system based on seeking the views of service users. The findings of these reviews must be made available to service users. All staff must received supervision at least 6 times a year. The home must have a photograph of every service user. Previous timescale of 28/10/05 not met. The home must keep copies of the duty rosters and a record of the hours actually worked by each member of staff. This record must be available for inspection. DS0000056120.V279133.R01.S.doc 26/01/06 24/02/06 18 OP30 18 28/04/06 19 OP32 26 24/03/06 20 OP33 24 28/04/06 21 22 OP36 OP37 18 17(1)(a) 28/04/06 24/03/06 23 OP37 17 24/02/06 Pollard House Version 5.1 Page 26 24 OP38 13(4) 25 OP38 23(4) The registered persons must make sure that portable electrical appliances are tested before they are used. All staff working in the home must have fire safety training at least twice a year. Previous timescale of 30/09/05 not met. 24/03/06 24/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP5 OP13 OP26 OP28 OP38 Good Practice Recommendations When an emergency admission is made the residents should be informed of the terms and conditions of residency within 5 working days. Staff in the home should be more proactive about offering facilities for visits to take place in private. Carried forward from the last inspection. The colour coding system for cleaning equipment should conform to the recommendations of Environmental Health. 50 of care staff should be qualified to NVQ level 2 or equivalent Accident records should be stored in individual files to comply with Data Protection law. Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Pollard House DS0000056120.V279133.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!