Inspection on 26/10/05 for Potton House Nursing Home

This inspection was carried out on 26th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Potton House Nursing Home 20/02/08

Potton House Nursing Home 10/10/07

Potton House Nursing Home 19/04/07

Potton House Nursing Home 11/05/06

Potton House Nursing Home 04/07/05

Potton House Nursing Home 24/01/05

Potton House Nursing Home 08/06/04

Potton House Nursing Home 06/01/04

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

CARE HOMES FOR OLDER PEOPLE Potton House Nursing Home Potton Road Biggleswade Bedfordshire SG18 OEL Lead Inspector Georgia Chimbani Unannounced Inspection 26 October 2005 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 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. Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Potton House Nursing Home Address Potton Road Biggleswade Bedfordshire SG18 OEL 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) 01767 314782 01767 314862 Health & Care Services (NW) Limited Patricia Sandra Pearson Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24) Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can accommodate a maximum of 24 service users. The home can continue to accommodate the identified service user who is aged under 65 years. The home cannot admit any other service users aged under 65 years. Date of last inspection 4 July 2005 Brief Description of the Service: Potton House is a purpose built care home with nursing situated in the grounds of Biggleswade Hospital on the outskirts of Biggleswade in mid Bedfordshire. Biggleswade has good road access and there is a limited bus service with the nearest train station in Sandy. Potton House provides places for up to twenty four older adults with mental health care needs. The home is single story with accommodation separated into three wings with their own living areas as well as some communal space. The home has a large garden and there is a large parking area at the front. Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Present at this unannounced inspection was the manager Ms Patricia Pearson. The inspection was 4 hours and 30 minutes in duration. As part of the inspection process the inspector attempted interviews with 7 service users however these were unsuccessful due to the nature of their mental health problems. Interviews were held with 4 relatives. Feedback indicated that although generally they were happy with the care provided at the home there were some areas of concern. These have been addressed in this report. 8 requirements were made at the last inspection. 4 requirements were met and 4 are restated. Restated requirements relate to activities, staff training, staff references and fire safety. The requirement regarding activities is restated for the third time. The registered persons are urged to give priority to restated requirements to avoid the possibility of enforcement action by the CSCI. A further 13 requirements are made following this inspection bringing the total number of requirements following this inspection to 17. The manager is confident that compliance will be achieved as the recent recruitment of a Deputy Manager will help to lighten her current workload. What the service does well: What has improved since the last inspection? Adjustable beds have been purchased for 6 service users assessed as requiring them. Weighing scales suitable for mobile and immobile service users have also been purchased. Radiator covers have been installed throughout the home. Staff interviewed were able to demonstrate awareness of their duties in the event of a fire. Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 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. Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 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 Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 There has been progress in staff training however more work is required in this area to ensure that staff have the necessary skills to adequately meet service user’s needs. EVIDENCE: At the previous inspection requirements were made for adjustable beds to be provided to service users who were assessed as requiring them and for all staff to receive training in dementia, managing challenging behaviour and mental disorder. The manager informed the inspector that 6 adjustable beds had been purchased for service users assessed as requiring them. During a tour of the home the inspector was able to see evidence of adjustable beds in service user’s rooms. The manager showed the inspector the home’s training matrix that indicated that 10 staff had received training in managing challenging behaviour. The training matrix did not however differentiate between dementia, challenging behaviour and mental disorder therefore it was difficult to determine the specific areas of training received by the 10 named staff. A restated requirement is made for the registered persons to ensure that all staff working in the home receive training in dementia care, managing challenging Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 9 behaviour and mental disorder. Records must clearly indicate the name of the member of staff, the course they attended and the date. Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 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): 9 and 10 Medication practices in the home are satisfactory and ensure the health and safety of service users is maintained. EVIDENCE: The nursing staff on duty administer medication. Medication is stored in a “treatment room” that is kept locked. Checks of medication records revealed that one controlled drug was available in the home. Accurate and up to date recording was seen on the controlled drugs register. Medication is administered through blister packs that are delivered monthly by a pharmacy. Medication administration record [MAR] sheets were inspected. These were up to date and appropriately completed. The home has a contract with Health Care Environmental for the disposal of medication. Disposal of medication and the accompanying records are carried out and countersigned by two members of staff. The temperature in the treatment room is maintained through an internal air conditioning system that automatically regulates the temperature. During lunch a member of staff was observed feeding two service users at the same time while standing in between them. This was considered inappropriate and showed little respect for the service users. The registered persons must Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 11 ensure that staff work in a way that respects service users and upholds their privacy and dignity. Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 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 and 13 The lack of meaningful, structured activities at the home leaves service users restless and lacking stimulation. Flexible visiting times ensure that service users are able to maintain links with their family, friends and local community. EVIDENCE: At the previous inspection a requirement was made for meaningful activities to be provided following consultation with service users and their relatives. Discussions with the manager revealed that care staff are responsible for facilitating activities every afternoon. There is no activities timetable and records are maintained only of visits by external entertainers. Interviews with some care staff confirmed that activities were held most afternoons however it is the inspector’s opinion that the facilitation of activities depended on the staff on duty and their willingness to engage service users. The inspector saw no evidence of service user activities in the home except for two service users engaged in colouring and playing with building blocks with a member of staff, towards the end of the inspection. The inspector was concerned that there was little stimulation for service users and many were seen wandering aimlessly around the home. This requirement is restated for the third time. The registered persons must ensure compliance with this requirement to avoid the possibility of enforcement action. Visitors were observed arriving and leaving Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 13 the home at various times throughout the day. Interviews with some relatives confirmed that there were no restrictions on visiting. One relative stated “I can visit even at the crack of dawn if I wanted to.” Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The lack of recording of complaints does not give service users and their relatives confidence that their complaints will be taken seriously. The lack of an internal adult protection policy and procedure together with the lack of staff training call into question the home’s ability to deal with adult protection issues. EVIDENCE: The home’s complaints procedure was displayed on the wall near the front entrance. The procedure meets the national minimum standards but the name National Care Standards Commission [NCSC] must be changed to Commission for Social Care Inspection [CSCI]. This is required. The manager informed the inspector that the home has received no complaints hence no complaints record was available. The inspector queried where complaints would be recorded if they were received. The manager advised that these would be recorded on service user’s care plans but the inspector advised that a separate complaints record must be kept. Discussions with some relatives revealed that they had made complaints to the manager, these had been resolved but the inspector saw no record of any of these complaints. The registered persons must ensure that a record of all complaints and the action taken is available for inspection by the CSCI. Staff training records indicated that not all staff have received adult protection training. A multi-agency adult protection protocol for Bedfordshire and Luton was available in the home however no policy or procedure for the home was available. The inspector was concerned that the lack of an internal adult Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 15 protection procedure meant staff were not clear on the processes to be followed in the event of an allegation of abuse being made. This was confirmed in interviews with staff. The registered persons must ensure the home has an adult protection policy with step by step procedures on the action to be taken by staff in the event of allegations of abuse being made. All staff working in the home must receive adult protection training. Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 16 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, 22 and 26 The home does not currently provide a consistently clean, safe and comfortable living environment for all service users. EVIDENCE: At the previous inspection a requirement was made for radiator covers to be fitted throughout the home. The inspector saw evidence of radiator covers around the home however a number of other areas were identified as requiring attention. The hallway carpets require cleaning or replacement, there was wallpaper and paint peeling from the wall in some service user rooms. The manager advised that new lace curtains had been fitted throughout the home however the effect of the new curtains could not be appreciated because of the poor standard of décor around the home. The curtains in the conservatory looked tired and skirting boards around the home had paint peeling off. The standard of cleanliness around the home was unacceptable and offensive odours were detected in some rooms and en-suite bathrooms. The odour in one room was so offensive that the manager asked for the room to be cleaned again. An improvement was noted following the second clean. Another room had an unsightly stain on the door and cobwebs were seen on the windows of Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 17 several rooms. The general environment of the home was not at all welcoming. Beds in some rooms had been poorly made with no attempt to shake out or straighten the bed linen. This gave the impression that the service user had just woken up when in fact the room had been cleaned and the bed made. The manager explained that funding for a maintenance programme had just been approved but no maintenance plan was available yet. The registered persons must ensure the home is maintained clean and hygienic and all offensive odours eliminated. Specified areas of the home must be redecorated and made good. A maintenance programme with including relevant dates must be sent to the CSCI. The home has a smoking room set aside for the use of staff. This room also serves a dual purpose of a staff recreation room. The inspector expressed concern that staff that do not smoke had nowhere to sit during their lunch break. The manager informed the inspector that staff could sit in the conservatory however as this is meant for the use of service users it was not considered appropriate for staff to use this room during their breaks. A relative interviewed by the inspector echoed this concern. They expressed concern that that the smoking room door was often left open and as a result the smell of cigarettes could be smelt in the corridor and sometimes in service user’s rooms. This relative added that some staff tended to use one of the quiet rooms for their breaks and as a result relatives and service users could not use this room. The inspector encouraged the manager to review the staff smoking arrangements as current arrangements did not adequately cater for the needs of non-smoking staff and could have adverse effect on the health and comfort of service users. The registered persons must ensure that suitable facilities are provided for service users to meet their visitors in private. A requirement made at the previous inspection relating to suitable weighing scales is met. The home has purchased new weighing scales suitable for mobile and immobile service users. Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 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): 29 and 30 Information obtained relating to staff references must be improved and staff training and development plans must be up to date. This will ensure that staff are fit to work in the home and are able to meet the needs of service users. EVIDENCE: 4 staff files were examined and most of the required documentation was available. Application forms on individual files contained information on the member of staff’s employment history. One file did not contain evidence of the member of staff’s eligibility to work and another did not contain a recent photograph. The registered persons must ensure that documentation confirming staff eligibility to work and a recent photograph is available for all staff working in the home. Criminal Records Bureau [CRB] checks were seen for all four staff. Where staff had commenced employment before their CRB check returned, a Protection of Vulnerable Adults [POVA] first check was available. All files contained two references however the requirement made at the last inspection for references to be verifiable was still not met. References were written on a standard form sent out by the home but there was no indication that the authenticity of the references had been confirmed. Where staff had previously worked in a position involving work with vulnerable adults or children their references did not include the reason for leaving their previous employer. This is required. The inspector queried how a member of staff’s fitness could be established using the limited information on the reference form. The current reference format does not ask the referee to confirm the job title and duties performed by the member of staff. It is therefore debatable as to how their performance in a previous job can be related to the work they are Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 19 expected to perform at Potton Nursing Home. The inspector also noted that some references were supplied by former colleagues or in one case a subordinate. This raises questions as to the reliability and validity of the reference. It is recommended that the registered persons review the reference request form with a view to ensuring it gives a more comprehensive overview of the member of staff’s roles and responsibilities in their previous job. A reference from a previous line manager might also give a more accurate picture of the member of staff’s performance. Records of staff training could be found in three types of documentation, the home’s training matrix, training attendance forms and individual employee training records. Certificates on file confirmed information contained in the training matrix. For example certificates seen indicated that a member of staff had received training in adult protection, infection control and challenging behaviour however their individual training and development was not completed. Therefore it was difficult to establish how and when their training needs in areas such as manual handling, food hygiene and fire safety were going to be met. The registered persons must ensure that an up to date training and development plan is available for all staff working in the home. Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 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): 34, 35 and 38 The home must implement a quality assurance to ensure that the views of service users and stakeholders are sought and acted upon. Written confirmation from the Fire Authority must be sought regarding locked gates on the perimeter to ensure that the health and safety of service users is promoted. The financial interests of service users must be protected through accurate records. EVIDENCE: There was no evidence to indicate that the home has carried out a quality assurance exercise in the last year. The manager advised that this was organised and carried out by the Head Office and she was unaware of any recent developments relating to this. The registered persons must ensure that a quality assurance system is implemented. This must seek the views of Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 21 service users, their relatives and other professionals. A report of the findings and any recommendations must be compiled and made available to the CSCI. The home keeps small amounts of money of no more than £100 each on behalf of service users for incidental expenses. A random check of a service user’s financial records showed that records were up to date and receipts were available for any expenditure. Some records were dated differently to the actual purchase date on the receipt. The registered persons must ensure that all records relating to service user finances are maintained accurately. At the previous inspection a requirement was made for the home to consult with the fire authority regarding padlocks on the perimeter gate and for staff to be confident in their duties in the event of a fire. Discussions with the manager revealed that the fire authority had been consulted and had given their agreement for the perimeter gates to be locked. This was on the proviso that keys to the gates were kept in the home with the keys to the treatment room that would always be held by the person on duty. No documentation was available to confirm this agreement therefore this requirement is restated. Interviews with two members of staff confirmed that they were aware of their duties and the procedure to be followed in the event of a fire. Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 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 X 3 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X 3 X X X 1 STAFFING Standard No Score 27 X 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 X X 2 Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 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 OP4 Regulation 18(1)(a) (c) Requirement Timescale for action 15/11/05 2 OP10 12(4)(a) 3 OP12 16(2)(m) (n) 4 OP16 22(8) A restated requirement is made for the registered persons to ensure that all staff working in the home receive training in dementia care, managing challenging behaviour and mental disorder. Records must clearly indicate the name of the member of staff, the course they attended and the date. [Previous timescale of 30/9/05] The registered persons must 26/01/06 ensure that staff work in a way that respects service users and upholds their privacy and dignity. Meaningful activities of the 26/11/05 service users’ choice or arising out of consultation with relatives, and based on current best practice must be provided for service users throughout the day. [Previous timescales of 31/3/05 and 30/9/05 not met] The registered persons must 26/01/06 ensure that a record of all complaints and the action taken is available for inspection by the DS0000017688.V258882.R01.S.doc Version 5.0 Potton House Nursing Home Page 24 5 6 OP16 OP18 22(7) 13(6) 7 OP18 13(6) 8 OP19 23(2)(b) (d) 23(2)(b) 16(2)(k) 23(2)(d) 23(2)(e) (g)(i) 19 Sch 2 9 10 OP19 OP26 11 OP26 12 OP29 13 OP29 19 Sch 2 14 OP30 17(2) 4.6(f) 18(1)(c) CSCI. The name NCSC must be changed to CSCI on the complaints procedure. The registered persons must ensure the home has an adult protection policy with step-bystep procedures on the action to be taken by staff in the event of allegations of abuse being made. The registered persons must ensure that all staff working in the home must receive adult protection training. The registered person must ensure that areas detailed under standard 19 in the body of this report are addressed. A maintenance programme with including relevant dates must be sent to the CSCI by 26/11/05 The registered persons must ensure the home is kept clean and hygienic and all offensive odours eliminated. The registered persons must ensure that suitable facilities are provided for service users to meet their visitors in private. The registered persons must ensure that documentation confirming staff eligibility to work and a recent photograph is available for all staff working in the home. The registered persons must ensure that staff references are authentic and verifiable. Where staff have worked in a position involving vulnerable children and adults, their reference must include written confirmation as to their reason for leaving. [Previous timescale of 31/7/05 not met.] The registered persons must ensure that an up to date training and development plan is DS0000017688.V258882.R01.S.doc 26/01/06 26/01/06 26/01/06 26/01/06 26/11/05 26/11/05 26/01/06 26/01/06 15/11/05 26/01/06 Potton House Nursing Home Version 5.0 Page 25 15 OP33 24 16 OP35 17(2) Sch 4 para 9 23(4) 17 OP38 available for all staff working in the home. The registered persons must ensure that a quality assurance system is implemented. This must seek the views of service users, their relatives and other professionals. A report of the findings and any recommendations must be compiled and made available to the CSCI. The registered persons must ensure that all records relating to service user finances are maintained accurately. The fire officer must be consulted about the padlocks on the perimeter gate. Documentation must be avaialble confirming their agreement. [Previous timescale of 31/8/05 not met.] 26/01/06 26/11/05 15/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations It is recommended that the registered persons review current smoking practices within the home with a view to ensuring a safe and comfortable working environment for all staff. It is recommended that the registered persons review the reference request form with a view to ensuring it gives a more comprehensive overview of the member of staff’s roles and responsibilities in their previous job. A reference from a previous line manager might also give a more accurate picture of staff performance. 1 OP29 Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Potton House Nursing Home DS0000017688.V258882.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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