Inspection on 14/09/06 for Pulsford Lodge

This inspection was carried out on 14th September 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pulsford Lodge 20/05/08

Pulsford Lodge 27/02/06

Pulsford Lodge 06/09/05

Pulsford Lodge 22/02/05

Pulsford Lodge 27/07/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Pulsford Lodge North Street Wiveliscombe Somerset TA4 2LA Lead Inspector Gail Richardson Unannounced Inspection 14th September 2006 09:40 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 Pulsford Lodge DS0000016051.V309665.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. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pulsford Lodge Address North Street Wiveliscombe Somerset TA4 2LA 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) 01984 623569 01984 624766 sonya.matthias@somersetcare.co.uk Somerset Care Limited Mrs Sonya Elizabeth Matthias Care Home 39 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. REGISTERED FOR 39 PERSONS IN CATEGORIES OP AND DE (E) Date of last inspection Brief Description of the Service: Pulsford Lodge is situated in the heart of the small town of Wiveliscombe. All local amenities are within a short walk and the home benefits from views over the surrounding countryside. The home was purpose built in the 1970s. The home is very much part of the local community and enjoys good relationships with local professionals. The home is set on two floors with a passenger lift large enough to accommodate wheelchairs, all internal areas are accessible to people who have mobility difficulties. The home is undergoing major refurbishment and building work, at this time, and will be increasing the accommodation to provide care for up to 50 service users by end 2006. Pulsford Lodge is registered with the Commission for Social care Inspection to provide personal care to up to 39 people who are over the age of 65, including older people with a dementia. The home is not registered to provide nursing care. The home is owned by Somerset Care Ltd. The registered manager is Sonya Matthias, and the responsible person is Marion Osborn. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over 1 day (7 hours) on the 14th September 2006 by inspectors Gail Richardson and Pippa Greed. A tour of the home took place and all the bedrooms and communal areas were seen. There were 32 service users currently residing at the home, this included 1 service user receiving respite care. The inspectors spoke to10 service users, 1 visitor ,.and 9 members of staff, the registered manager Sonya Matthias was also available within the home on the day of inspection. All residents spoken to, and who were able, told the inspector that they were happy at the home and with the care they are receiving. They were all complementary about the kindness of the staff. As part of this inspection the inspectors surveyed the opinions of a random selection of service users and their representatives, GP’s, District Nurses and Care Workers. A good amount of responses were received from service users, relatives/visitors and staff. Records relating to care including three care plans, staff files, finances and health and safety records were examined The inspectors noted that on the day of inspection, there was still considerable building work underway, however considerable lengths have been taken to ensure that service users were not too inconvenienced by the ongoing work or the levels of noise. Staff spoken to, were happy to be employed at the home and felt supported by the management of the home. The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. What the service does well: Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 6 Time spent by the inspector observing staff, evidenced that they were kind and caring towards service users and spoke to them at all times with support and reassurance. It was evident that staff have a clear understanding of the service users care needs and are able to support them to maintain independence. Records examined relating to the care given to service users and their families at a time of bereavement showed great care and support for all concerned. The home demonstrated that further support is sought from other health professionals to ensure that a high standard of care and understanding of service user needs at this time are met. The home is working well to maintain a level of hygiene whilst the building work is underway The administrative and management staff are organised and efficient and records relating to staff files, personal finances and maintenance were up to date and comprehensive. Medication systems are well organised. The quality and variety of meals is much enjoyed and appreciated by service users. What has improved since the last inspection? What they could do better: Further development of the recording of activities to evidence an outcome. For example is the service user participated and enjoyed the activity and how it could be developed further to support the service user. The home is recommended to ensure that all staff who have undertaken dementia care training have this recorded in their training record. The home is further recommended to ensure that all staff clinical supervision undertaken is recorded in the staff file. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 7 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. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12345 The overall quality rating for this section is assessed as good. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. All prospective service users are assessed by the manager and member of the staff team Prospective service users, relatives and friends are able to visit the home prior to admission. EVIDENCE: The home has produced a Statement of Purpose incorporating the Service User Guide which is made available to service users, prospective service users and their representatives. The manager confirmed that on completion of the current building work an updated copy will be made available. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 10 Service users were able to confirm that they or their relatives had been able to view the home prior to admission. Each service user had received a preadmission visit by the Manager or a representative from the home. One survey comment included “Staff visited Mummy at home before we visited the home and had the opportunity of looking around and asking any questions before making a decision” Their needs were assessed and documented. Further information from other health care professionals is also taken into account. One contract was examined and contained all the required information. Further detail of what the contract covers in the rate of fees is contained in the service user guide. The homes current fee range is between £361.00 to £470.00 for residential care and nursing care. Pulsford Lodge DS0000016051.V309665.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 11 The overall quality rating for this outcome group has been assessed as good. There was first hand evidence of good care outcomes for service users, however, the care planning system adequately provided enough information to support the care needs of the service users The medication systems within the home are good. Personal support was offered in such a way as to maintain privacy and dignity of service users. The service evidenced for service users at the time of their death showed sensitivity and a high level of care and support to both the service users and their families. EVIDENCE: 3 service user care plans were examined in detail. These included all risk assessments, care plans and daily records. These records evidenced that all aspects of care had been recorded and are reviewed regularly. Risk assessments are undertaken and reviewed , these included the risk assessments for service users who self medicate. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 12 There was evidence that visiting health professionals are involved in the care of service users. There was further evidence that service users are involved in the assessment of their needs. The inspectors’ evidenced staff dealing with service users in a kind and considerate manner and were seen treating service users with dignity and respect. All surveys received confirmed that service users felt that staff listened and acted on what they said. One comment made was “I can speak to any of the staff. They are always very helpful.” And “Staff are very patient” Medication systems were good. Medication Administration Records were clear and had no unexplained gaps. Staff are currently transferring from one medication system to a new service and all systems seen for the ordering, procurement, administration and disposal were of a good standard. All creams stored in service users rooms were seen to be named and dated on opening. The recording of creams and dietary supplements is recorded within the service users care plan. Lockable storage facility was provided within the service users room for all service users who were able to self medicate. The inspector examined the care records for one service user who had recently died. The records contained a care plan which was regularly reviewed with the changes in care needs. It contained the details the service user wished following their death and the wishes and requests of the family. Evidence was available of the support of visiting health professionals at this time. There was further evidence of the support given to the family, enabling then to stay at the home overnight. The manager confirmed that staff are very aware of the need to ensure all care and support is given at this time. Comments were received o the relatives /visitors surveys which confirmed that relatives were very happy with the care given at this time. Pulsford Lodge DS0000016051.V309665.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): 12 13 14 15 The overall quality rating for this outcome group has been assessed as excellent. Social activities are well managed and provide daily variation and interest for people living in the home. Further development of recording these activities is recommended. Service users are able to exercise choice and control over their lives. Relatives and visitors are always welcomed by friendly staff. The home provides a varied and wholesome diet with a wide variety of choices available. EVIDENCE: The home employs one member of activity staff for 25 hours per week, who provides a variety of activities throughout the week. This is planned one week in advance. Activities are selected to meet service user preferences. The activities are advertised on a notice on the corridor of the home. On the day of inspection the activity noted and undertaken was a Church Service. This took place in the downstairs lounge and was well attended. One Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 14 service user of an alternative faith to the one noted above, was able to confirm that a separate service for three service users is organised monthly. The hairdresser was also available within the home on the day of inspection and appeared to be a social occasion. A variety of activities and trips were seen and a planned trip to Exmoor was being organised for the following day. The manager confirmed that specific activities were planned for service users with dementia care needs. A recorded overview of all service users who participated is maintained Further development of the recording of activities is recommended to evidence an outcome. For example, if the service user participated and enjoyed the activity and how it could be developed further to support the service user. Service user surveys responded to a question about are activities available, with,3-always,1-usually. Service users confirmed that visitors could visit at any time were always made very welcome by the staff. Service users rooms were personalised to each individual’s own tastes with personal items and small pieces of furniture. Breakfast is served from 8.30 am onwards and a full English breakfast is available every day. The menu is planned in collaboration with staff and service users and new options are discussed at Residents Meetings. Lunch on the day of inspection was Ham/cheese Salad with Sauté potato or vegetable stew and mashed potato. Desert was, bread and butter pudding with custard, rice pudding with peaches, ice cream, fruit and arctic roll. There was a varied range of meals available and the majority of service users ate in the dining room. Staff confirmed that some service users do eat in their rooms. The foot was appetising and plentiful and service users were able to confirm that the standard of food is always high. The menu is posted on a board by the door and staff moved from table to table discussion menu options. The dining room has recently been refurbished and is light and airy, tables are laid attractively. No service users required any assistance with eating and drinking and there was plenty of staff on hand to serve lunch. All service users surveys confirmed that they liked the food. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 15 The inspectors discussed how best to organise the transportation of service users to the dining room as on service user was brought to the dining table at 12md and lunch was not served until 1pm. The manager confirmed that this was not normal practice. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 16 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 17 18 The overall quality rating for this outcome group has been assessed as good. The home has a complaints procedure that is up to date and clearly written Service users legal rights are protected. The policies and procedures and record keeping, regarding protection of residents are of a good standard. EVIDENCE: Service users and staff were all able confirm the procedure for making a complaint. All were confident that the complaint would be taken seriously and responded to. All service users are registered to vote. Training on adult protection issues are undertaken by staff at induction, in conversation, staff demonstrated a good understanding of abuse awareness. Staff surveys received all stated that they were aware of how to report any concerns about poor care practices or allegations of abuse. The home maintains policies and procedures for whistle blowing and abuse awareness which are regularly reviewed. Pulsford Lodge DS0000016051.V309665.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 20 21 22 23 24 25 26 The overall quality rating for this outcome group has been assessed as good. The home is a large building with a further extension being built. Current temporary systems are in place to support service users during the building work Bedrooms are personalised to reflect individual taste. Bathrooms and toilets are provided in sufficient numbers and are clean. Control of infection practices in one bathroom are recommended to be reviewed The homes environment is able to meet the assessed needs of the service users. The home is clean and hygienic EVIDENCE: The inspector made a tour of the home and saw all bedrooms, communal areas , kitchen and laundry. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 18 The home was clean and appeared managing well under the circumstances involved in the building work. The building site manager confirmed that building staff had been instructed to be sensitive to the needs of current service users. Periods of time during the day had been designated quiet times by the builders and this was evidenced during the church service and mealtimes. One service users comment made was “Even with the building works, the girls try very hard to keep it clear.” Service users bedrooms are personally decorated and well maintained. All corridors were ramped and handrails available. There is ample communal space available, with newly fitted lounge areas on both floors. There is access to specialist equipment and adaptations to promote independence. Specialist pressure relieving cushions and mattresses were seen were there was an assessed need. All wheelchairs were seen to be clean and individually labelled. Toilet and bathing facilities are provided in sufficient numbers and were clean and odour free. The ground floor bathroom was noted to have clothing protection aprons for staff available. One of these aprons appeared unclean and this was discussed with the manager at the time of inspection The general standard of cleanliness was good. The laundry staff confirmed that they received sufficient training and that they considered the hours sufficient to maintain the laundry of the home. The inspectors toured the laundry facilities on each floor and appear clean and well organised. Suitable arrangements have been made to minimise any risk of cross infection. Pulsford Lodge DS0000016051.V309665.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 The overall quality rating for this outcome group has been assessed as good. The home’s staffing levels are sufficient to manage the current care needs of residents and residents have confidence in the staff that cares for them. The homes management of staff training is well organised but requires that all training undertaken is recorded on the staff members training record. The homes recruitment procedures are robust and complete and protect the service user. EVIDENCE: The Registered Manager and other staff members confirmed that they felt there were enough staff on duty to meet service users needs. On the morning of inspection there was 1 supervisor, 1 shift leader and 3 care assistants. The manager was also available throughout the day. There was also 1 activity coordinator, 2 kitchen staff, 2 cleaning staff, 1 laundry staff , 1 admin staff and 1 maintenance staff. The afternoon shift consisted of , 1 supervisor and 3 care assistants and the night shift consists of one supervisor and 1 care staff. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 20 The home has used agency staff recently to cover annual leave and retirement of staff. The manager confirmed that she also has access to Somerset Care’s bank nurse scheme. As part of the pre inspection questionnaire the manger had provided a list of all staff training undertaken and the inspectors also examined the staff training register and also discussion with the staff members. All staff receives induction training and further mandatory training updates. Training in other specialised areas is also undertaken. 64 of staff have completed NVQ2. The inspector could see no record of dementia care training within the training record or training details made available. The inspector recommends that as dementia care is part of the homes registration staff training in dementia care is undertaken and recorded in the staff training records. Domestic staff had access to data sheets and had received training in the use of the chemicals provided. Service users had confidence that the staff could care for them and were very complementary about the standard of care provided. All service users spoken to, said that the staff were very kind and helpful. Three staff files were evidenced. These staff members had been employed since the previous inspection. All contained evidence of a thorough company recruitment process. The staff employed all had evidence of POVA First and CRB checks. . Pulsford Lodge DS0000016051.V309665.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 32 33 34 35 36 37 38 The overall quality rating for this outcome group has been assessed as excellent. The home benefits from the positive leadership style of the manager The management of finances and records related to this are well maintained. Records inspected were maintained well and were stored in a confidential manner. The Health and Safety records are good. EVIDENCE: The home has an established management structure and service users and staff benefit from this positive leadership. The manager Mrs Sonya Matthias has many years management experience and is clearly very involved in the Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 22 running of the home on all levels. She has completed the level 4 Registered Managers Award. One service user survey comment made was “The Manager (Sonya) is so very kind and has helped me a lot.” The manager has made every effort to communicate with service user/relatives/visitors and staff to enable the smooth running of the home during the building work including letter and meetings and a general good level of communication. Quality assurance questionnaires were last sent out in 25th July 2006 and were available for the inspector. Relatives surveys received by CSCI all said that they were happy with the overall care provided. Service users personal finances were held in an appropriate and secure manner. Each service user had their own record of transactions, containing and balance and receipts and an individual pocket of money. This was randomly audited by the inspector and found to be correct. Routine auditing of all personal finances by the administrative staff takes place. Generally staff supervision records were good and evidenced that staff receive supervision regularly and this is then used to develop further training needs. It was noted that staff supervision is not recorded 6 times per year. The manager explained that staff do receive supervision but it is not always recorded, for example, in the instances of staff meetings. The inspectors recommended that all supervision is recorded. This supervision is recorded in the staff members files. One comment from a staff survey was “We have a very god support system here at Pulsford “ The policies and procedures for the safe storage of records and documents meet the requirements under the Data Protection Act. Maintenance records were seen, these included ; * * * * * * * * * * * Fire Extinguishers Hoist Servicing Emergency lighting PAT Tests COSHH Hot water temperatures Gas Servicing Electrical Hard Wiring Fire System Lift servicing Nurse call servicing DS0000016051.V309665.R01.S.doc Version 5.2 Page 23 Pulsford Lodge * Accident audit. Maintenance records were well maintained and up to date. The home has received an inspection by the Health and Safety Executive on the 21/03/06 and the outcome was satisfactory. Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 24 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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP12 Good Practice Recommendations The manager is recommended to develop the recording of activities further to record if service users enjoyed the activity and any improvements or developments that could be made. The manager is recommended to ensure that staff training in dementia is undertaken and recorded on staff training records. The manager is recommended to ensure that all staff receive supervision 6 times per year that all staff supervision is recorded 2. 3. OP30 OP30 Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Pulsford Lodge DS0000016051.V309665.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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