Inspection on 28/06/06 for Riddlesden Rest Home

This inspection was carried out on 28th June 2006.

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

Riddlesden Rest Home 17/01/08

Riddlesden Rest Home 14/03/07

Riddlesden Rest Home 09/11/05

Riddlesden Rest Home 23/11/04

Riddlesden Rest Home 03/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Riddlesden Rest Home Carr Lane Riddlesden Keighley West Yorkshire BD20 5HQ Lead Inspector Sughra Nazir Unannounced Inspection 28th June 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Riddlesden Rest Home DS0000051070.V297698.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. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Riddlesden Rest Home Address Carr Lane Riddlesden Keighley West Yorkshire BD20 5HQ 01535 604504 F-P 01535 604504 N/A 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) Mrs Helen Leach Mrs Helen Leach Care Home 10 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (10) of places Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider must undertake and complete the registered manager’s award by 31 March 2005 9th November 2005 Date of last inspection Brief Description of the Service: Riddlesden Rest Home is situated on the outskirts of Keighley. The home is a single storey adapted building, providing ten single bedrooms. There is car parking to the front of the building and good wheelchair access. The home does not have any gardens, but there is a fenced patio area at the back of the building that provides good views over the valley. The home is registered to provide care for up to ten service users of either sex over the age of 65, the home can also provide care for up to three service users over 65 with dementia. Fees range from £332.50- £342.50 – information provided by the manager at inspection on 28th June 2006. Arrangements for sharing inspection reports need to be made clear. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection carried out under Inspecting for Better Lives. An approach that is introducing proportionate inspection activity based on the level of risk identified at the home. All services will have at least one key inspection between April 2006 and June 2007. Due to the significant number and nature of requirements outstanding from previous inspections this home was rated as poor. The visit to the home was carried out by two inspectors who each took 7 hours to gather information and speak to the residents and staff before giving the manager detailed feedback. Prior to the inspection visit, a pre-inspection questionnaire was sent out to the manager for completion. This was returned and the information has been used to inform the visit. In addition, surveys were sent to the home for completion by residents and their relatives. What the service does well: What has improved since the last inspection? The home has completed work to the exterior to enhance the appearance and safety of outdoor space. The patio has been replaced and raised beds created. Some work has been carried out in response to a fire safety inspection and report. Carpets have been replaced in the lounge and sun lounge. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 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. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 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 Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 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): 1, 3 5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a risk that residents do not get all the written information they need about the home. EVIDENCE: The statement of purpose is dated June 2003. This means that this is not upto-date. The service user guide includes some questionnaires developed for an annual survey but the arrangements for sharing inspection reports are not made clear. Both documents must be reviewed and updated to make sure that residents and their relatives have up-to-date information about the home. It was clear that there are more residents in the home with dementia as their main care need than the home’s registration categories allows them to take. The manager must make sure that the registration category reflects the needs of those people living at the home. She was advised that she must apply for a variation to the registration categories. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 9 One resident has been admitted in the last three months. The manager visited them in order to assess their needs. The pre-admission assessment record was clear and detailed and gave a picture of the residents needs. The manager also requests copies of assessments that have been done by other health care professionals. The home will assist residents to find alternative accommodation if it becomes clear they are no longer able to meet the resident’s needs. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans are still being formulated and this means residents needs may not be met. Medication records are incomplete and this places residents at risk. EVIDENCE: It was clear from talking to residents and staff that the needs of residents are being met. However it was not possible to check all this information in records as care plans are poorly developed. The home is small and intimate and staff have a very good knowledge and understanding of the residents, their needs and how to meet them but there is not enough documentation to support this. The manager is making very slow progress with the care plans and has only started on two with the new documents that she intends to use. Making sure that all residents have clear and detailed care plans in place must be made a priority. This will mean that residents care needs in relation to Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 11 religion; culture, lifestyle and preference can be identified and that individual care needs are not overlooked. The two care plans that the manager has been working on were looked at. From reading daily records it was clear that residents’ health care needs are identified and met. Visits are requested as needed from GP’s and district nurses. The plan for one resident showed that a referral to the dietician had been requested from the GP but not if it had been done. The nutritional risk assessment had not been completed. The manager said the form was too complicated, she was advised to contact the dietician for a tool that all staff could use. A falls risk assessment had been filled in which showed that the resident was identified as at high risk of falling in February 2006, a care plan had not been put in place. But it did show that when staff were concerned about the residents mobility and unsteadiness when walking they contacted the GP for advice. The manager should contact the falls prevention team for support and advice about carrying out assessments and putting appropriate care plans in place. A notification of a fall was sent through to the Commission which said that the resident had injured her head but no GP had been called. Daily records were kept and there were some detailed and informative entries. Appropriate accident records were seen but the manager must make sure that they are dated and signed when the outcomes of the accident are followed up. One of the care workers was giving residents their morning tablets as they got up and came for their breakfast. The home is now using a monitored dosage system with medication administration record (MAR) sheets produced by the supplying pharmacist. The carer’s practice was safe and they checked the MAR before giving tablets and signed it when they were taken. They said that they had done medication training through a local college. On checking the charts however the morning tablets for the day before had not been signed for Staff were observed talking to residents throughout the day and treated residents with respect. The glazed panels in bedroom doors contain frosted glass and privacy is ensured through net coverings. One bedroom has a clear glass panel and this is covered to make sure that the resident’s dignity is maintained. Residents’ wishes in respect of illness, dying and death have not been recorded. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 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, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents enjoy some choice and have their needs met but there is no documentation to support this. EVIDENCE: It was clear throughout the visit that there were very good relationships between staff and residents. The home is small and intimate and has a family atmosphere. It was clear one resident was close to the manager and they said ‘they are lovely here to you’. Other comments from residents included ‘I am happy here’ and ‘the girls are so nice to us’. There was no programme of activities displayed. Staff said that they are able to spend quality time with residents when their duties were completed and they had a good insight of each individual’s abilities and preferences for social stimulation. Interests are not recorded. One of the carers took two residents out for a walk and said that this was a regular occurrence. A shopping trip to Keighley for all residents was planned at the end of the week. After lunch two residents stayed at the dining table playing dominoes and another was doing a large jigsaw puzzle. Staff said that some of the residents looked forward to and enjoyed playing computer and other games with the manager’s children. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 13 Not all residents were up when the visit started and it was clear that they could choose when to get up. Staff said residents choose when to go to bed as well. At lunchtime there was only one choice of main course but alternatives can be given if the residents do want it. Staff said that the meal plans are put together after talking to residents about likes and dislikes. Such preferences are not recorded and this information may be lost if residents ability to understand or express their needs changes. The table was nicely set at lunchtime and meals attractively served. The meal was relaxed, unhurried and a nice social occasion for the residents. They were chatting to each other and staff. Where help was needed it was given in a discreet way. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 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, 17 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents may not know who to complain to if they are not happy and they cannot be sure that staff know how to protect them from abuse. EVIDENCE: No complaints policy is displayed in the home so the manager cannot be sure that residents or their relatives know how to complain. Information about who to complain to and the timescales for a response should be clearly displayed for residents and visitors to the home. No information was available to show how many complaints had been received in the past year. The manager said that arrangements had been made for residents to vote with all those able to do so, travelling to the polling station. Two residents received postal votes. Staff were aware of the adult protection procedures and said they would not hesitate to report any concerns if they thought residents were at risk of abuse. But formal training around adult protection has not been received by all staff. . Residents said that they felt safe and cared for. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents do not have access to all the facilities they need but the home is clean. EVIDENCE: The manager has continued to make improvements to the building and gardens. The patio has been repaved, a small flower garden has been added and wrought iron fencing put up. This now gives residents a nice place to sit outside with views over the valley. New carpets have been fitted in all communal areas and new fire doors added to the sun lounge. The manager said that there are also plans to refurbish the bathroom, which will include a new shower that will be accessible to residents. The rooms are all single with wash hand basins but no ensuite facilities. Commodes are provided if needed. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 16 All bedrooms were clean and tidy and showed that residents had brought personal items with them. They have a light over the sink unit as well as the main ceiling light. This means that they can access a light while in their bedroom. Main light switches are located outside bedroom doors, which is unacceptable. Two residents have been provided with bedside lamps. The manager said that other residents were at risk of injury if lamps were provided. This needs to be recorded in individual files. No lockable facilities are provided. One bedroom is still without a wardrobe. The vanity unit in one bedroom was damaged. The manager was aware of this and said that it was due to be replaced in the near future. Other vanity units are showing signs of wear and tear and will need to be replaced. The home was clean and tidy and there were no smells. Residents’ clothes were nicely laundered. The manager said that the laundry walls still need to be resurfaced and that no red bags are available for soiled linen. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service.” The home’s recruitment practices and training for staff do not always support and protect residents. EVIDENCE: There were two care staff on duty plus the manager. One of the care workers was also cooking the lunch, which had been prepared by the manager. Staff said that they had enough time to meet the needs of residents as well as do extra duties such as the cleaning and meal preparation when needed. They said that there is normally an extra member of staff on duty who is allocated to do the cooking. They said that they liked working at the home because they could spend quality time with the residents. The rota was looked at and showed that the manager’s hours were often not recorded accurately and did not show the actual hours she was working. The manager said that there was a staff vacancy and she was looking to employ another carer. A recently employed care worker said that they had completed a one-week induction and introduction to the home. The training given covered COSHH, moving and handling, fire safety and medication awareness. They were Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 18 experienced and had attended training courses through previous employers, one of which was NVQ (National Vocational Qualification) level 2. They were keen to progress to level 3 and attend any other courses needed to look after residents in the home. The CRB (Criminal Records Bureau) check for this employee had been carried out by a previous employer and a new check was being fast-tracked. The manager was advised that CRB checks are not portable and cannot be taken from one employer to the next. The manager said that confirmation of a clear POVA first check was provided by the umbrella organisation but there was no record of this. The manager must make sure that for every employee she keeps full records of employment documentation, including completed application forms, two written references, proof of identity, terms and conditions and evidence of required checks. The manager said that she explored gaps in employment history but no comments were recorded on the application form for one employee with two gaps in their employment history. There were no interview records. One member of staff said that the manager was proactive in finding and arranging training courses for them to attend. They had completed NVQ level 2, moving and handling, first aid, health and safety, food hygiene and dementia. They had not done training on identifying and preventing abuse as required in previous inspections. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 19 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, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards of care are maintained but record keeping is poor. EVIDENCE: The manager has now provided evidence of a management qualification. Staff said that the manager was approachable and supportive. They felt that residents received very good care because the staff team worked together and supported each other. They said that communication systems were good and they all knew what changes had taken place. They were given a ‘handover’ at the change of every shift. A recognized system of quality assurance is not used although the manager now has drafts of questionnaires available, more work needs to be done to consult residents to make sure decisions are made in their best interests. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 20 A carer said that they had received formal supervision three months ago when they had discussed training needs and oral care. There were no supervision records. The manager must recognise the importance of regular supervision and introduce regular recorded supervision sessions for all staff. Information about hazardous substances is now kept in a file. Risk assessments for specific areas are still needed such as for the step from the sun lounge onto the patio. There is no visitors or signing in book. This means the home does not have a record of who is in the building. The manager said that as water is not stored in the building legionella checks are not required however checks to ensure that hot water temperature does not exceed 43 degrees Celsius must be carried out and recorded. The manager does not have a business plan. It was suggested that the manager consider such issues as business continuity, financial viability and marketing. Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 21 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 2 X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 X X X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 2 2 2 2 2 Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4,5,6 Requirement The statement of purpose must be kept under review and contain up-to-date information about accommodation and facilities available and contain service users views. Information with regard to how service users are consulted about the operation of the home and how to access a copy of the most recent inspection report must be added to the Service User Guide. (Previous timescales of 31st March 2005 and 31st March 2006 have not been met) A service user plan of care must be formulated from all relevant assessments, with the involvement of the service user and their representatives. The care plans must clearly evidence how service users physical, medical and social needs will be met. The care plans must be reviewed monthly. Previous timescales of 30th June 2005 and 31st March 2006 have not been met. Nutritional screening must be DS0000051070.V297698.R01.S.doc Timescale for action 30/09/06 2 OP7 15 30/09/06 3 OP8 14 30/09/06 Page 23 Riddlesden Rest Home Version 5.2 introduced with screening on admission. A record must be kept of nutrition and weight loss and gain and follow up action must be recorded. Previous timescale of 31st January 2006 has not been met 4 OP9 13 All medication administration records must be completed. Previous timescale of 31st January 2006 has not been met The wishes of residents in relation to death and dying must be established and recorded. Previous timescale of 31st March 2006 has not been met Opportunities must be provided for stimulation through leisure and recreational activities that meet the needs, abilities and preferences of service users. Previous timescale of 31st March 2006 has not been met The complaints policy must be provided to all residents in a format that suits their needs if requested. Previous timescale of 31st January 2006 has not been met The registered manager must make sure all staff have training on adult protection. The requirements of the fire safety survey carried out in January 2004 must be implemented. A full audit of all maintenance and repair work must be carried out and timescales set for when these works will be completed. A copy of this must be forwarded to the DS0000051070.V297698.R01.S.doc 31/08/06 5. OP11 12(1) 15(1) 30/09/06 6. OP12 14(1(a) 4(1)(a) 30/09/06 7. OP16 22 (1)-(6) 30/09/06 8. OP18 13 31/12/06 9. OP19 23 31/08/06 Riddlesden Rest Home Version 5.2 Page 24 CSCI. Previous timescale of 31st March 2006 has not been met 10. OP24 23, 16 (2) (i) Suitable furniture must be made available for the storage of clothes and provision of other furniture as required by this standard. The home should ensure that any surface protection materials used on bedside cabinets is made safe Residents should be provided with keys unless there is a risk assessment is in place showing why this is inappropriate. Lockable storage facilities must be made available in all bedrooms and residents supplied with keys. Timescale of 30th June 2006 extended. 11. OP26 13 (3) The laundry walls must be refinished to ensure that these surfaces are readily cleanable. Red bags for soiled must be made available at all times. The home must provide and ensure that protective clothing is worn when serving food to prevent the spread of infection. Powder - free gloves must be made available to staff with allergies. Previous timescale of 31st January 2006 has not been met The staff rota must provide an accurate record of staff on duty and in what capacity. Previous timescale of 31st January 2006 has not been met The home must continue implementing the NVQ training programme Timescale of 30th DS0000051070.V297698.R01.S.doc 30/09/06 31/12/06 12. OP27 18 31/08/06 13. OP28 18 31/03/07 Riddlesden Rest Home Version 5.2 Page 25 June 2006 extended 14. OP29 19 The registered person must ensure that written references and confirmation of satisfactory enhanced CRB disclosure and POVA checks are in place before offering employment to prospective staff. Previous timescale of 31st January 2006 has not been met Manager must ensure that all staff receive training on dementia care and on adult protection. The manager must introduce strategies for enabling service users and other stakeholders to affect the way in which the service is delivered. Previous timescale of 31st March 2006 has not been met The quality assurance policy must be implemented and a system of obtaining comments and feedback from the service users and other stakeholders must be developed. The results of these must be made available to interested parties. Previous timescale of 30th June 2005 and 31st March 2006 have not been met A business plan must be put in place, which must be reviewed annually. Previous timescales of 30th June 2005 and 31st March 2006 have not been met Secure facilities must be provided for the storage of valuables. Previous timescale of 31st March 2006 has not been met. DS0000051070.V297698.R01.S.doc 31/08/06 15 OP30 18 31/12/06 16. OP32 20 30/09/06 17. OP33 25 31/12/06 18. OP34 25 (1) 30/09/06 19. OP35 23 31/12/06 Riddlesden Rest Home Version 5.2 Page 26 20. OP36 18(2) Care staff must be formally supervised at least 6 times a year. Supervision should cover all aspects of practice, the philosophy of care in the home and career development needs. Records should be maintained and development plans formulated for individual members of staff. Previous timescale of 31st January 2006 has not been met The manager must ensure that all required records are kept by the home and that they are up to date. Previous timescales of 31st December 2004 and 31st January 2006 has not been met Risk assessments must be carried out in order to make proper provision for the health and welfare of service users and staff. Records of these must be available. The manager must ensure safe working practices including the implementation of temperature checks of hot water outlets. The registered provider must review the registration categories and apply for variation in registration. The registered provider must keep a record of all visitors to the care home. Action required to implement CSCI requirements must be taken to agreed timescales. An improvement plan must be submitted to the Commission. 30/09/06 21. OP37 17 30/09/06 22. OP38 12,13 31/08/06 23. *RQN Section 15 CSA 200 30/09/06 24. *RQN 17(2) 31/08/06 25 *RQN 24 31/08/06 Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP1 OP7 OP14 Good Practice Recommendations The service user guide should provide details of the views of service users. Training should be accessed for staff with regard to record keeping and care planning in particular. Residents’ preferences in relation to social activities, food and their environment should be established. Residents should be consulted and involved in decisions about their home. Up-to-date information about activities should be circulated to all service users in formats suited to their capabilities. The complaints policy should be displayed in a the home and copies given to all service users, relatives, visitors, etc. The registered person should ensure that written records are kept of verbal references obtained. All staff should be issued with the GSCC code of conduct booklet Training and development plans should be put in place for each member of staff. An overall programme for all training would assist the home to plan, monitor and record all training taking place. 4. OP12 6. OP16 7. OP29 8. OP30 Riddlesden Rest Home DS0000051070.V297698.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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