CARE HOMES FOR OLDER PEOPLE
Primrose House Primrose House Perry Hill Worplesdon Guildford Surrey GU3 3RF Lead Inspector
Lisa Johnson Unannounced Inspection 09:40 19th May 2006 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 Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Primrose House Address Primrose House Perry Hill Worplesdon Guildford Surrey GU3 3RF 01483 232628 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) primrose.house@ntlworld.com Mrs Anne-Marie Antoinette Beeharry Mr Ahmad Issac Beeharry Mrs Anne-Marie Antoinette Beeharry Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (16) of places Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Of the 16 (sixteen) accommodated 4 (four) may fall within the category of DE(E) The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE 26th September 2005 Date of last inspection Brief Description of the Service: Primrose House is a large house in the Worplesden district on the main road to Guildford. The home is close to a pub and the village hall. Public transport provides links to Guildford. The home is registered for sixteen older people, some of whom have mental health needs. There is a large garden to the rear of the house and parking facilities are available at the front. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes first key inspection carried out in 2006/2007.The unannounced inspection took place over eight hours and was carried out by Mrs. L Johnson. The registered manager was unavailable for this inspection. Mr. A Beeharry responsible individual represented the establishment. A full tour of the premises was undertaken and care plans, staff files and policies and procedures were sampled. The inspector spoke to two members of staff. The inspector spoke to three service users and spent time with three other service users who due to communication difficulties were unable to give their views about the care and support that they receive in the home. Other information was gained from observation of service users within the home. The inspector spoke to three service users and spent time with three other service users who due to communication difficulties were unable to give their views about the care and support that they receive in the home. Other information was gained from observation of service users within the home. The service users involved in discussion all commented positively towards the care they received at the home. However a number of matters requiring action remained outstanding since the inspection 26th September 2005 and other matters needing immediate attention were identified as part of this inspection process. The inspector would like to thank the service users, relatives and staff for their hospitality and cooperation during this inspection What the service does well:
The service has a homely atmosphere and is nicely decorated and well furnished. Gardens are well maintained which service users can access during the summer. Staff were observed to be talking to service users in a friendly and respectful manner and service users were observed to be relaxed in their company. It was pleasing to see staff and service users taking part in activities. The home has updated its quality assurance systems, which are based on feedback from service users and relatives, and a number of positive comments have been received. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 6 The inspector received a number of positive comments from service users for example “I would recommend this home it feels like home and the staff are kind and caring”. “This is a lovely place-very nice”. “The staff are very good and friendly”. What has improved since the last inspection? What they could do better:
A number of requirements made during the last inspection dated 26th September 2005 had not received action by the provider. The Commission has decided to give extended timescales for some of these requirements. A failure on the part of the provider to meet the requirements within the stated time frame may result in a statutory notice being served under regulation 43 of the Care homes regulations 2001 (as amended). Two care plans were sampled which were not signed by the individual or their representative and photographs were not available for each service user. This information was required at the previous inspection and has not received action. A further requirement was made that this information is completed with an extended timescale for achievement to ensure that service users are fully involved in the care planning process. The inspector sampled the medication administration records and some gaps were found where staff have not signed the recording cards. The original requirement has not been met. Immediate requirements were made that staff
Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 7 must sign the medicine card when medication has been administered to individuals to ensure that service users are protected by the homes medication policies and procedures. It was also recommended that where medication is transcribed on to the medication card that this should be checked and signed by two staff where possible and photographs should be supplied with their records. A t the previous inspection a requirement was made that the complaints procedure was made available in the homes Statement of Purpose on examination this information was still not available. A further requirement was made that this is actioned to ensure that resident’s and relatives/friends have the information they require and that they are confident that complaints will be listened to. The home had received one complaint and the inspector sampled documentation. The issue raised with the home was not reported following the local authority safeguarding adult’s policies and procedures and was also not reported to the Commission for Social Care Inspection. An immediate requirement was made that all incidences that fall under the remit of safeguarding adults must be reported immediately to ensure that service users are protected from abuse. A further immediate requirement was made that all serious incidences must also be reported without delay to the Commission for Social Care Inspection. It was also required that the manager introduces a local safeguarding adults policy which makes reference to the local authority multi-agency policies and procedures and all staff are aware of this procedure to ensure that residents are protected from abuse. The duty rota was sampled and the sleep-in shift start and finish times were not recorded. A requirement was made that this information is recorded to ensure that service users are supported by the appropriate numbers of staff. It was required that further numbers of staff need to undertake training in National Vocational Qualifications (level 2). This is to ensure that at least fifty percent of the staff have qualifications to be able to support service users safely. During discussion with the responsible individual it was evident that POVA first checks were not completed prior to new staff commencing employment in the home and that he was not aware of this process. This was raised as a serious concern and immediate requirement was made that these checks must be completed for all new staff employed to ensure that service users are protected by the homes recruitment policy and procedures. Two issues in respect of health and safety were identified. Fire records were examined and the most recent record of the last fire drill was not available. An immediate requirement was made that a fire drill is carried out and that the Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 8 written record must be maintained. Covers must be supplied to all radiators in the home. This is to ensure the health, welfare and safety of service users. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 9 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 Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 10 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): 1&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that pre admission assessments are completed prior to admission to the home. The home does not support service users for intermediate care. EVIDENCE: Copies of assessments completed by health professionals making referrals were available on individual files. The registered manager visits prospective service users to carry out their assessment. A further assessment is completed within one week of admission. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Each service is provided with an individual care plan, which details the individual’s health, personal, emotional and social needs. Further work is required in ensuring that service users and/or their representatives sign individual plans where possible to ensure that they are fully involved in their process. Further work is required to ensure that service users are protected by the homes medication policy and procedures. Service users privacy and dignity is respected. Improvements are necessary regarding outstanding requirements from the previous inspection. This area has been assessed as poor in view of the number and nature of the outstanding requirements for example medication which have not received action since the last inspection. EVIDENCE: Two care plans were sampled and were detailed and comprehensive and progress has been made in updating and reviewing goals monthly. Risk
Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 12 assessments have been updated including for example mobility. Plans are reviewed six monthly and evidence was provided to the inspector that reviews have been completed with service users and/or their representative. However individual plans had not be signed to confirm their agreement. A further requirement was made that service users and/or their representatives should agree and sign their care plans to ensure that service users are involved in the drawing up of their plan. A requirement was also made that a photograph should be made available of each individual with his or her plan. These two requirements remain outstanding from the previous inspection. Service users have access to a range of health care professionals including a local GP, chiropody, dentist, optician and district nurse. Records were maintained for monitoring weights for all individuals The inspector sampled the medication administration records and some gaps were found where staff have not signed the cards. The original requirement made has not been met. Immediate requirements were made that staff must sign the medicine card when medication has been administered to individuals to ensure that service users are protected by the homes medication policies and procedures. It was also recommended that where medication is transcribed on the medication card that this should be checked and signed by two staff where possible. It is also recommended that a photograph of individuals be maintained with their records. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 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 the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users engage in a range of leisure activities and are supported to exercise choice. Service users are able to maintain links with their family and friends. Service users are offered a well balanced diet EVIDENCE: Individual’s preferences in respect of hobbies and interests are incorporated in the care plan with religious needs identified. There is an activities programme is place. During the inspection a hairdresser was visiting and all the service users were enjoying having their hair done. An activities person visits the home weekly; the home holds a church service and pets for therapy visit. During the inspection a group of service users and staff were playing a game of dominoes together which everybody was enjoying. There are occasional, shows and a staff member stated that they go on walks to the local park, which was confirmed by one service user. The home provides CDs and DVDs and some service users were observed to have newspapers, which are ordered, by the home. One individual stated that she had seen a concert. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 14 Service users maintain contact with family and friends and there are no restrictions. During the inspection a relative was seen visiting the home. Service users are able to see relatives in private if they so wish and there is a separate sitting area in place. Service users are able to bring personal possessions into the home, which were seen, on display in individual’s rooms. The home has carried out two service users meetings this year and the minutes were sampled. One individual stated they liked listening to modern music with the manager responding to this request. The homes menu was sampled and choices can be accommodated. The lunchtime meal was well balanced. Service users spoken to were satisfied with the meals provided. During the inspection service users were offered drinks and biscuits. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 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 the following standard(s): 16 &18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure but this needs to be accessible to service users and relatives to ensure that they have the information should they wish to raise a concern. The staff team need to ensure that it responds to the protection of vulnerable adult policies to ensure that residents are protected from abuse. EVIDENCE: A previous requirement was made that that the complaints procedure must be made accessible as part of the homes Statement of Purpose. The original requirement has not been met and a further requirement was made that an accessible complaints procedure must be made available to ensure that service users and relatives/friends have the information they require if they wish to raise concerns. The inspector observed that staff were friendly and spoke to users in a respectful manner. Four service users spoken to confirm that they are happy living in the home and that staff are approachable and comments included” I would recommend this home, it feels like home and the staff are kind and caring”. “The staff are very good and friendly”. The home has received one complaint, which was received several months ago and pertained to a safeguarding adult issue. It was concerning to note this issue was not reported following the local authority safeguarding adults policies and procedures and was investigated internally by the home. An
Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 16 immediate requirement was made that the registered manager and staff should report any incidents or allegations that fall under the remit of safeguarding adults immediately to the local authority and to the Commission for Social Care Inspection. A further requirement was made that the registered manager should introduce a local safeguarding adults procedure, which makes reference to the local authority policies, and procedures to make all staff aware of the procedures to ensure that residents are protected from abuse. Training records sampled indicated that staff have received training on safeguarding adults with the responsible individual and registered manager having attended the local authority safeguarding adults training. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 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 the following standard(s): 19, 23, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely environment, which is well maintained and furnished. Service users have comfortable bedrooms to stay in. The home is able to demonstrate that it is clean and hygienic ensuring that service users have a pleasant environment to live in. EVIDENCE: A full tour of the premises was undertaken and there was homely atmosphere. The home has completed extensive redecoration work, which has enhanced the appearance of the home. The garden was well maintained and is accessible for service users to use in the summer Improvements have been made to the front of the house and a number of windows have been replaced. Toilets were accessible to the lounge and toilet areas and were clearly labelled with pictures to assist service users. Bedrooms were well maintained, personalised and comfortably furnished
Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 18 with service users being given the opportunity to bring in some of their own furniture if they so wish. The home employs an ancillary staff member and the home was cleaned to a good standard. Separate laundry facilities were in place. The kitchen was hygienic and clean with a good awareness of food hygiene practices. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing levels were sufficient to meet the needs of service users but needs to maintain an accurate record of all hours worked by sleep-in staff. The home must ensure that at least fifty percent of staff have completed National Vocational Qualifications. The homes recruitment practices did not promote the safety of service users as POVA first checks not being completed The home is able to demonstrate that staff receive training and development ensuring that are able to meet the needs of service users. EVIDENCE: During the inspection there was three staff on duty plus an ancillary staff member. At nighttime there is one waking and one sleep-in person. However the hours of the sleep-in person were not recorded. A requirement was made that this must be recorded to ensure that an accurate record is maintained of staff on duty to ensure that the appropriate numbers of staff meets service users needs. The inspector was informed that three staff commencing are National Vocational Qualifications. However the manager needs to ensure that at least fifty percent of the care staff hold National Vocational Qualification (Level2) to
Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 20 ensure that service users are supported by fifty percent of the staff must complete National Vocational Qualifications. This is to ensure that service users are supported by suitable and qualified staff to promote their health and wellbeing. The inspector sampled two staff personal files, which contained the required documents. Police checks were completed. However during discussion with the responsible individual it was evident that POVA first checks have not been completed before new staff have commenced employment in the home. The responsible individual stated that he was not aware of this process. This was raised as a serious concern and immediate requirement was made that that POVA first checks must be completed before any member of staff commences employment in the home. This is to ensure that the health, welfare and safety of service users is protected. Training records were sampled for two members of staff, which confirmed that staff are receiving training and development, which was verified by training certificates held on files. Courses attended included for example, safeguarding adults, food hygiene, fire safety, dementia awareness, medicine training, first aid, care planning and health and safety. All staff receive induction training. One member of staff spoken to confirmed that he had completed training in first aid, medicine administration and food hygiene. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The registered manager holds appropriate qualifications and is experienced to manage the home. The home is able to demonstrate that quality assurance systems have been implemented. The financial interests of service users are protected. Three health and safety issues need addressing to ensure the health, welfare and safety of service users. To ensure that the home is run in the best interests of service users, the management need to take action to meet the requirements made during the last inspection and those identified as part of this inspection. EVIDENCE: A number of requirements made during the inspection dated 26th September 2005 had not received action by the management and registered persons. The Commission has agreed an extended timescale for some of these matters. The
Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 22 registered provider needs to take action to meet the requirements in the agreed time frame. A failure to meet the requirements may result in the serving of a statutory notice under the Regulation 43 of the care homes regulations 2001 (as amended). Both the responsible individual and the registered manager hold nursing qualifications and the registered manager holds the registered managers award. The home has updated quality assurance questionnaires based on feedback and the home has responded to a recommendation to update service user meetings. Some monies are maintained by the home on behalf of service users. Records were sampled which were in order. Any expenditure is documented with receipts maintained. Health and safety records were sampled which were adequately maintained. However a record of the last fire drill was not available. An immediate requirement was made that an updated fire drill is completed with a record of the outcome documented. An immediate requirement was made that all serious incidences are reported the Commission for Social care Inspection without delay and that all staff working in the home are aware of the procedure and their responsibilities. A further requirement was made that all the radiators require covers to ensure the health, wellbeing and safety of service users. Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 X X X 3 X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 24 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. Standard Regulation 1 OP7 15(2)(a) Requirement Timescale for action 19/07/06 2 OP9 13(2) 3 OP16
Primrose House 4(1)(c) Schedule 1 a) The registered persons must ensure that care plans are agreed and signed by residents and/or their representatives where service users are unable to sign, this must be recorded (with the reason) in the individual care plan. b) Photographs must be supplied with individuals care plans. (Previous requirement 26/12/05 not met). a) The registered persons must 19/05/06 ensure that all medication administration records are signed by the staff on each occasion that medication is administered to a service user (and the relevant code entered where medications is not administered for any reason) b) An audit trail must be implemented to follow up any gaps in signing the medication administration records. (Previous requirement 14/10/05 not met. A copy of the complaints 19/06/06 procedure must be made available
DS0000013751.V295455.R01.S.doc Version 5.2 Page 25 4 OP17 5 OP17 6 OP28 7. OP29 8. OP38 9. OP38 10. OP38 with the homes Statement of Purpose. 16(6) The registered person must implement a local policy for safeguarding adults that makes reference to the local authority safeguarding adult’s policies and procedures. 13(6) Any incident that falls into the remit of safeguarding adults must be reported without delay to the local authority social care team. 18(1) The registered person must ensure that at least fifty percent of care staff have obtained National Vocational Qualifications (level 2) 19(1)(2)(3)(4) The registered persons must Schedule 2 ensure that POVA first checks are competed prior to any new staff commencing employment in the home. 23(e) The registered person must complete an up to date fire drill and maintain written records. Fire drills must be carried out on a regular basis. Consultation should take place with the relevant fire safety officer to establish a suitable frequency in respect of fire drills. 37 The registered persons must ensure that all serious accidents and incidents are reported to the Commission for Social Care Inspection without delay and that all staff working in the home must be made aware of the procedure. 13(4)(a) The registered person must ensure that covers are provided to all radiators in the home 19/06/06 19/05/06 19/08/06 19/05/06 19/05/06 19/05/06 07/09/06 Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 26 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 OP9 OP16 Good Practice Recommendations The registered manager should consider including a photograph of each resident with the medication administration records. The registered manager should consider making a complaints log book accessible to service users and visitors Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Primrose House DS0000013751.V295455.R01.S.doc Version 5.2 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!
