Inspection on 28/04/08 for Rosehill House

This inspection was carried out on 28th April 2008.

CSCI found this care home to be providing an Adequate service.

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

Rosehill House 21/04/09

Rosehill House 01/05/07

Rosehill House 02/05/06

Rosehill House 13/09/05

Rosehill House 09/06/05

Rosehill House 24/02/05

Rosehill House 02/06/04

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Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Rosehill House Keresforth Road Dodworth Barnsley South Yorkshire S75 3EB Lead Inspector Michael O`Neil Key Unannounced Inspection 28th April 2008 09:20 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 DS0000018266.V362921.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. DS0000018266.V362921.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosehill House Address Keresforth Road Dodworth Barnsley South Yorkshire S75 3EB 01226 243 921 01226 297 978 NONE NONE Mr Azad Choudhry Mr Aurang Zeb Manager post vacant Care Home 27 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) Category(ies) of Old age, not falling within any other category registration, with number (27) of places DS0000018266.V362921.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st May 2007 Brief Description of the Service: Rosehill House is situated on the outskirts of Dodworth Village. It is approximately three mile from Barnsley town centre and ten minutes drive from the M1 motorway. The home is a detached property within its own grounds, providing personal care for 27 elderly people. There is car parking space to the front, side and rear of the property. To the front of the property is a large patio/terrace with garden furniture. Ramps are provided to the main entrance at the side of the building and to the patio. Access to the patio can also be gained via the patio doors from the lounges. The accommodation is on two floors. A passenger lift is provided. The Service User Guide, the Statement of Purpose and the home’s last inspection report were displayed in the main entrance. Fees were £351.50. Hairdressing, toiletries and newspapers were not included in the weekly fee and were charged separately. This information was provided on 28th April 2008. DS0000018266.V362921.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is ‘1 star’. This means that the people who use this service experience adequate quality outcomes. The person present at the inspection was: Pat Smith, operations manager of the company, which owns Rosehill House. The homes previous manager resigned her position in January 2008. Pat Smith has been overseeing the overall management of the service since that time. Prior to this visit the operations manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of this report. The actual site visit took place over a six and a half hour period. During this time opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the service, check the services policies and procedures and talk to 5 staff, 4 relatives and 9 people who live at the home. We checked all key standards and the standards relating to the requirements outstanding from the services last inspection in May 2007. The progress made has been reported on under the relevant standard in this report. We wish to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well: Evidence was seen that the home were regularly consulting with and requesting reviews from health professionals when the person’s needs were quite complex and had been changing. People looked clean, well dressed and appeared to have received a good level of personal care. People said DS0000018266.V362921.R01.S.doc Version 5.2 Page 6 “The staff are very friendly and they are great” “I’m very happy here” “The staff are lovely and kind” Relatives said “Staff are very caring” “The staff are brilliant” “I’m kept informed about what is going on and whenever I visit the staff are always the same friendly, kind and helpful” Relatives spoken to said they were able to visit at any time and were made to feel very welcome. People said that the food was good and said that choices were available at all meals. The home was clean and tidy and no unpleasant odours were noticeable. Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. People, staff and relatives said they knew who the owners of the home were and saw them regularly. What has improved since the last inspection? There had been positive action on the requirements listed within the last inspection report. The majority of requirements had been acted upon and resolved. Overall though there seemed to have been a significant improvement in the standard of the care plans and the recordings made by staff. The frequency of activities available for people has improved since the last CSCI visit. The external grounds have been landscaped and a new patio built. This has improved the homes grounds. DS0000018266.V362921.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. DS0000018266.V362921.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 DS0000018266.V362921.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3.Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before moving into the home to make sure it is the right place for them to live. Pre admission information ensured the home was able to meet peoples health, social and care needs. This home does not provide intermediate care services. EVIDENCE: Three peoples files were checked and each contained a copy of their full needs assessments. Prior to admission taking place, professionals and staff from the home assessed people. This confirmed that the service was appropriate for the person and provided staff with information to formulate an individual plan of care. DS0000018266.V362921.R01.S.doc Version 5.2 Page 10 Evidence was seen that the home were regularly consulting with and requesting reviews from health professionals when the person’s needs were quite complex and had been changing. The home does not provide intermediate care. DS0000018266.V362921.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from the provision of accurate care plans and were satisfied with the care and service being delivered. Some medication procedures need improving to ensure that people are protected. EVIDENCE: Three peoples care plans were checked. The peoples care plans checked were good in that they contained details about the person’s biography, personality and their preferences and choices. In the main previous requirements made at the last inspection had been addressed. The plans were being regularly reviewed and the changes in people’s health were being more closely observed and recorded. DS0000018266.V362921.R01.S.doc Version 5.2 Page 12 Daily records included details of people’s daily routines to help ensure that their health and welfare needs are met. Inventories of people’s personal property were now being recorded in more detail. However there was no evidence recorded in two care plans checked to show that people and/or their relatives were involved in drawing up and reviewing the care plans. Overall though there seemed to have been a significant improvement in the standard of the care plans and the recordings made by staff. People looked clean, well dressed and appeared to have received a good level of personal care. People said “The staff are very friendly and they are great” “I’m very happy here” “The staff are lovely and kind” Relatives said “Staff are very caring” “The staff are brilliant” “I’m kept informed about what is going on and whenever I visit the staff are always the same friendly, kind and helpful” Staff were seen to treat people with respect. People and relatives said that people were treated with respect and dignity and that staff listened and acted on what they said. Medicines were securely stored in locked trolleys within locked cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Staff said they had completed training on the safe administration of medicines and were due to undertake further training within the next month. There was evidence that the operations manager had been auditing medication administration procedures. People were not fully protected from medication administration errors because: Two of the MAR sheets contained hand written instructions with no signature as to the prescriber. Two staff members, who check that the correct information is documented, or ideally the General Practitioner should sign any handwritten instructions on the MAR sheets. DS0000018266.V362921.R01.S.doc Version 5.2 Page 13 When checking the Controlled Drug register we found that the records of one controlled drug were not up to date. There were no drugs missing but staff had miscounted the drug in the register and other staff had failed to notice the discrepancy for the last 7 days. Staff could not have been following safe medication procedures otherwise this error would have been found within 24 hours. DS0000018266.V362921.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. People were able to make choices about daily living and be involved in some social activities. Meals served at the home were of a good quality and offered choice to ensure people receive a balanced diet. However meals were not available at times convenient to some people. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. We saw that everyone coming to the home was offered hospitality and staff took time to make sure friends and family were made to feel comfortable whilst visiting. DS0000018266.V362921.R01.S.doc Version 5.2 Page 15 The home has appointed a staff member to undertake activities with people for 6 hours a week, which has meant that the frequency of activities available has improved since the last CSCI visit. Quizzes, games, crafts, and singing were advertised as taking place in the home. Relatives said that they appreciate that there was more stimulation for people at the home but that they would still like to see a further increase in the amount and type of activities available. On the day of the site visit staff were seen spending time with people on a one to one basis. An information board was sited in the dining room of the home. The information on the board however was out of date and did not contain sufficient detail that may help people with orientation. Information in larger brighter print such as the weather, a news item may help people with orientation to time and place and provide more stimulation. Food preferences were listed on people’s files. Within the dining room, however, a menu board was available but this was blank therefore people did not know what meals were available unless they asked. It was positive to see fresh fruit served in the morning for people who wanted it. Although the operations manager said that it was not the norm it was observed that the lunchtime period was not a positive experience for some people. We observed that prior to lunch being served at least 8 people were sat for periods of up to fifty minutes at dining tables. People were sat staring at each other without any stimulation and they were not even provided with a drink whilst waiting for the meal to be served. The tables were set nicely with cloths, condiments and matching crockery and when the meal was served people said “We always get a good meal” “The food is very good, with a lovely variety”. “I’m enjoying my food” Staff were supporting people with their meal in a polite and discreet way. DS0000018266.V362921.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced would be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: People and their representatives had been provided with a copy of the homes complaints procedure. The operations manager was updating some information on the policy before redisplaying it in the entrance hall to the home. The policy contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. People and relatives said they had no concerns about the home, staff or service provided. They said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. DS0000018266.V362921.R01.S.doc Version 5.2 Page 17 The Commission had been informed last year by the management of the home about some concerns. These concerns were taken through adult safeguarding procedures .A conclusion has not been reached yet however a plan has been agreed with the home and all other agencies to keep people safe. Staff had undertaken formal training on adult protection, which had equipped them with the skills needed to respond appropriately to any allegations. DS0000018266.V362921.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment within the home was well maintained, furnished to a good standard and clean, providing a comfortable, safe environment for people. EVIDENCE: The home was clean and tidy and no unpleasant odours were noticeable. Touches have been added to make Rosehill House feel more homely. Bedrooms checked were comfortable, homely and reflected peoples personal tastes. People said their beds were comfortable and bed linen checked was clean and in a good condition. DS0000018266.V362921.R01.S.doc Version 5.2 Page 19 The external grounds have been landscaped and a new patio built. The grounds of the home looked very pleasant. People said they were looking forward to the warmer weather coming so that they could sit outside in the newly landscaped gardens. DS0000018266.V362921.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were generally employed in sufficient numbers to meet the residents needs. Although some staff and relatives felt that levels were insufficient. Recruitment procedures promoted the protection of people and staff had completed training, including induction. EVIDENCE: The majority of people, staff and relatives said staffing levels were adequate. Relatives said that staff were usually very visible around the home when they visited. Some relatives and staff did raise some concerns over staffing levels at certain times during the day. The operations manager stated that agreed staffing levels were being maintained and the staff rota identified agreed staffing levels had been met. In view of the comments made, however, and due to the possible changing needs of people, an audit of staffing levels should be undertaken. Staff and people who use the service should also be consulted to highlight and address any areas of concern over the levels of staff employed. DS0000018266.V362921.R01.S.doc Version 5.2 Page 21 Four staff files were checked. The files contained a range of information including two references and a declaration of health and identification. The staff had undertaken a criminal record bureau check (CRB), at the enhanced level. For three members of staff recently recruited it demonstrated that a Protection Of Vulnerable Adults check had been carried out before they commenced employment. This confirmed thorough recruitment practices were in place, which was sufficient to safeguard people. Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff were able to talk about the various training courses that they had attended. Over 50 of the staff team had achieved their NVQ Level 2 or above and others were due to commence this training shortly. DS0000018266.V362921.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The procedures and ethos of the home ensure that in the main the home is run in the best interests of people who use the service. The services policies and procedures and some actions by staff mean that the health, safety and welfare of people is not fully protected. EVIDENCE: There is no manager in post at the moment. Pat Smith, operations manager, said she was very hopeful that an experienced manager could be in post shortly. DS0000018266.V362921.R01.S.doc Version 5.2 Page 23 In the meantime Pat Smith has been overseeing the overall management of the service. Pat has many years experience within the nursing and caring profession. She is committed to ensuring that people staying in the home were consistently well cared for, safe and happy. People staff and relatives said they were all happy to approach the operations manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. The home had a quality assurance system. There was evidence of internal auditing of the homes environment, services and records. Staff meetings were held and minutes of these meetings were seen. The responsible individual visited the home on a regular basis, a report was written following the visits. People, staff and relatives said they knew who the owners of the home were and saw them regularly. The quality assurance system does still need expanding, however, to ensure that the home was run in the best interests of the residents e.g. questionnaires and meetings. A sample of monies that was looked after on behalf of people living at the home was checked. Records were kept and money tallied with the records. The fire risk assessment had been reviewed in January 2008. Some actions required from the fire risk assessment were not being adhered to, as highlighted below. The health and welfare of people could not be fully protected, as: A door leading onto steep stone cellar steps was found unlocked despite a notice on the door stating that it must keep locked. If a disorientated person were to step through the door they would walk straight onto the steps and may be at risk of falling and sustaining a very serious injury. The alarm on the first floor fire door had been isolated. The alarm sounder would not actually switch off. Staff should have requested that this be repaired as opposed to isolating the alarm. Again people may be at risk of serious injury if they walked out onto the metal fire escape without supervision from staff. The fire risk assess stated that all staff must receive annual fire safety training and a monthly fire drill must be held to check staffs responses in the event of a fire. These instructions are not being adhered too. Some staff had not received recent fire safety training and fire drills were not being conducted monthly. DS0000018266.V362921.R01.S.doc Version 5.2 Page 24 Several people were being moved in an unsafe way. Staff were escorting people around the home in wheelchairs, which were not fitted with footplates. To minimise the risk of injury footplates must be used (unless risk assessment does not warrant this) when assisting people to mobilise in their wheelchairs. Staff said they had received some fire safety and other health and safety training .A sample of records showed that staff were receiving some statutory training but at varying degrees of frequency. At the time of the visit fire exits were clear and hazardous products were safely stored in the home. This will promote the safety and welfare of the people. DS0000018266.V362921.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 X 3 X X 2 DS0000018266.V362921.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement People and/or their relatives must be involved in drawing up and reviewing their care plans. Previous timescale of 01.07.07 not fully met. To ensure the safe storage and monitoring of drugs. An audit of medication records and the controlled drug register must be undertaken. Previous timescale of 03.05.07 not fully met. Meals at the home must be served at a times convenient to people who use the service. To minimise the risk of injury footplates must be used (unless risk assessment does not warrant this) when assisting people to mobilise in their wheelchairs. All parts of the home to which people have access are free from hazards to their safety. (Fire escape /cellar door) Adequate arrangements must be made for people to receive suitable training in fire DS0000018266.V362921.R01.S.doc Timescale for action 01/08/08 2. OP9 13 01/06/08 3. 4. OP15 OP38 16 13 01/06/08 01/06/08 5. OP38 13 01/06/08 6. OP38 23 01/06/08 Version 5.2 Page 27 prevention and the procedures to follow in the event of fire. (Fire risk assessment) 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 OP9 Good Practice Recommendations The Medication Administration Records should contain a General Practitioner or two members of staffs’ signatures alongside any directions regarding the name and dosage of the medication or the time the medication is to be dispensed. More and clearer information should be provided to help orientate people to date,time and place. People should be made aware of the meals on offer to enable them to make a positive choice. An audit of staffing levels should be undertaken. Staff and people who use the service should also be consulted to highlight and address any areas of concern over the levels of staff employed. The home’s quality assurance system should be expanded to ensure that the home is run in the best interests of people. (Surveys, meetings with the management of the service) 2. 3. 4. OP12 OP15 OP27 5. OP33 DS0000018266.V362921.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000018266.V362921.R01.S.doc Version 5.2 Page 29 - 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!