Inspection on 30/10/07 for Sapling

This inspection was carried out on 30th October 2007.

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

Sapling 14/10/08

Sapling 13/06/06

Sapling 02/11/05

Sapling 27/06/05

Sapling 25/10/04

Sapling 06/05/04

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

CARE HOMES FOR OLDER PEOPLE Sapling 372 Chessington Road West Ewell Surrey KT19 9EG Lead Inspector Helen Dickens Unannounced Inspection 30th October 2007 10:15 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 Sapling DS0000038846.V347085.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. Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sapling Address 372 Chessington Road West Ewell Surrey KT19 9EG 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) 020 8393 6731 Emas Ltd To Be Confirmed Care Home 4 Category(ies) of Learning disability over 65 years of age (4) registration, with number of places Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2006 Brief Description of the Service: Sapling is registered to provide accommodation and care to four older service users with a learning disability. The home is a purpose built bungalow and accommodation consists of a lounge area, a dining room, a newly built conservatory, a laundry room, bathroom with shower, toilets and four single bedrooms with their own toilet and hand basin. The home has a large garden to the rear of the property which is private, secure and accessible to service users, and private parking is available. The registered provider is Mr. Puah of Emas Limited. The current cost of a place at this home starts at £942 per person per week. Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 7 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The deputy manager, and the owner Mr. Puah, represented the establishment. A partial tour of the premises took place. The inspector spoke to all four residents during the day. Three questionnaires returned to CSCI prior to this inspection were also used in writing this report. Two resident’s care plans and a number of other documents and files, including two staff files, as well as risk assessments and maintenance records, were examined during the day. The Annual Quality Assurance Assessment completed by the home prior to the inspection has also been used in writing this report. The Commission for Social Care Inspection would like to thank the residents, owner and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: What has improved since the last inspection? Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 6 The majority of Requirements made at the last inspection have been met including up-dating the statement of purpose and service user guide, putting activity plans into a format which is more accessible for residents, and getting menu plans checked by a dietician. The complaints procedure has been up-dated and there is an infection control policy in place, as well as external training being given to staff on this subject. There are now more than 50 of staff with either an NVQ Level 2 or a registered nurse qualification. Regulation 26 visits have been carried out each month and fridge temperatures are regularly recorded and now within acceptable limits. 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. Sapling DS0000038846.V347085.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 Sapling DS0000038846.V347085.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents admitted to this home have their needs assessed and they are assured these can be met prior to moving in. EVIDENCE: Prospective residents are only admitted following a thorough assessment of their needs and the latest resident to be admitted had very detailed assessments on their file. Health professionals including the psychologist, occupational and physiotherapists, and care managers had all been involved. The owner does his own assessment and prospective residents can visit the home in advance to look at the facilities and spend some time with existing residents. Overnight stays can also be arranged. Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 9 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): 7,8,9 and 10 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care needs are set out in individual plans but these need to be reviewed more frequently. Health needs are met and there are satisfactory arrangements in place for the administration of medication. Residents are treated with respect. EVIDENCE: Two care plans were sampled and found to contain a good level of detail about residents needs across the 24 hour period. Assistance is documented under the activities of daily living and care plans note how residents would like that support to be delivered. The owner has already identified that the current plans could be more person centred and has started to re-design the current care plans into a more person centred framework. Some parts of the existing care plans are reviewed regularly every month. The owner and deputy manager were reminded that care plans for older people must be reviewed in full each month. Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 10 One file checked should have had a manual handling risk assessment and a falls risk assessment carried out by the home. On closer inspection, these risk assessments had been completed by the care manager and reviewed 3 monthly. However, the home should have their own assessments and, if they are intending to use those supplied by other professionals, they must ensure that they fully address the risks within the home, and are accessible to staff who support residents. This home has very close links with local health services which benefits residents. The residents files sampled showed a variety of interventions, carefully documented, in relation to visits and treatments.Guidelines drawn up by health professionals were on file and being followed by staff. Residents have health action plans in place. Two health professionals who completed questionnaires for CSCI made favourable comments including A comfortable and safe home and when asked what the home does well, one wrote Individual care, with respect for the person as an individual. The owner takes overall responsibility for ordering and collecting medication from the local pharmacy. Only those staff who have had training can administer medication to residents, and an external specialist trainer is used for this training. The storage arrangements were secure and the deputy manager spoken with was knowledgeable on the storage and administration of medication. There were no negative issues raised in relation to privacy and dignity on the day of the inspection. Staff were observed to be respectful to residents and attempted to include them in conversations and in what was going on in the home. Personal care was delivered in private and residents wear their own clothes and were dressed very individually. Questionnaires from a relative and two health professionals who visit the home confirmed that residents were well looked after and treated as individuals. Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 11 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): 12,13,14 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are some opportunities for social activities but the home must keep this under review to ensure residents are getting sufficient stimulation throughout the week. Family and friendship links are encouraged and residents are able to exercise some choice and control over their lives. Residents are offered a wholesome diet and enjoy their food at this home. EVIDENCE: Three residents activity plans are now in a pictorial format to make them easier for residents to follow. The deputy manager said the fourth resident had had their plan in a pictorial format but it was currently under review. The activity plans showed a number of day-time activities for residents including day care, Us-in-a-Bus, and a visiting music therapy session. The home keeps a separate log for each resident regarding what they have done with regard to activities on a particular day and this was examined and found to be regularly up-dated. However, the level of stimulation for residents needs to be reviewed because there were many sessions during the week when plans stated relaxing at home which in reality meant there may be little mental Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 12 stimulation. More opportunities should be found to provide meaningful activities for residents and a recommendation will be made in this regard. Residents are encouraged to keep up family and friendship links and staff spoken to were knowledgeable on residents families. Visitors are allowed at reasonable times. In addition to residents own bedrooms, visitors could also be seen in the dining room or the conservatory when these are not in use. One relative who returned a questionnaire to CSCI was very complimentary about the home noting The bungalow is of a very high standard. They also said Sapling is Homely and clean and Tenants are taken out and they go on holiday. Residents use local health services and some are involved in local churches. Residents also use local restaurants, and one helps with the food shopping at the supermarket. Residents at this home are given opportunities to make choices and the deputy manager gave some examples of how this works with one resident who does not speak. None of the current residents can manage their own financial affairs, and where there are no relatives willing or able to do this, the owner has made arrangements with social services and the Court of Protection to assist them. Residents can bring personal possessions with them when they move into the home and all four rooms visited were very personalised and comfortable. There is a documented menu in place, based on residents likes and dislikes. There is also a separate note kept when other meals, not on the planned menu, have been substituted. Menus have now been shown to a dietician which was a Requirement from the last inspection. Main meals were found to be satisfactory though a few recommendations were made with regard to snack lunches which the home has now implemented. In reality, the snack lunches are often replaced by something more nutritious, for example on the day of the inspection residents had a home-cooked roast chicken lunch rather than the spagetti on toast which was on the menu. The deputy manager said that when staff are on duty who enjoy cooking, they are more creative with lunches. Those who needed assistance were given help, though residents are encouraged to be independent and some adaptations, such as a plate guard and special cutlery are used by residents. Some residents needed their food cut up, and one needed their meat liquidised to avoid choking. This was clearly documented on care plans. Residents had a sausage casserole for their evening meal as per the menu and residents were seen to be enjoying their food. Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 13 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): 16 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s complaints would be taken seriously at this home and they are protected from abuse. EVIDENCE: There is a complaints policy in place and a user-friendly version for residents. There have been no complaints to the home or to CSCI since the last inspection and the complaints book was checked. The address for CSCI changed earlier in the year so this will need to be altered in the policy. On one questionnaire returned to CSCI the respondent ticked that they did not know how to make a complaint. The home may wish to circulate the latest version of the procedure, with the new CSCI details, to all stakeholders. There is an in-house protection of vulnerable adults policy which makes it clear that all suspected incidents of abuse must be reported to social services and the police where appropriate. There is also a copy of the local Surrey procedures in the home. The deputy manager and owner were clear that all instances should be reported and new staff are made aware of the policy during their induction – two induction records for staff were checked and this subject had been ticked and signed by the new employee and the owner. Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 14 The policy needs to be up-dated to contain the new Surrey contact Centre telephone number where all reports have to be made in the first instance. It was also noted that the home does not have a written policy on staff accepting gifts from residents. When asked, both the owner and the deputy were clear that the policy was that staff cannot accept gifts. The owner was asked to ensure there was a written policy and that this was circulated to staff. Sapling DS0000038846.V347085.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment which is clean and fresh throughout. However, more work is needed to promote the safety of residents. EVIDENCE: Sapling provides a very homely environment for residents with good quality furnishings and fittings. The new conservatory provides an extra space for residents which is comfortable and bright. Bedrooms are very personalised and comfortable. There is an aquarium in the lounge which was clean and wellkept. The owner was asked to get an occupational therapists assessment regarding the suitability of the ramp outside the conservatory as a handrail may need to be fitted for extra safety. This home does not have radiator covers but the owner now has a risk assessment in place, and will need to keep this under review as residents needs change. Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 16 This home is clean and odour free throughout. The laundry was clean and tidy and the door is kept locked. Staff now do an external course on infection control, and there is an infection control policy in place. The hazardous substances cupboard was not locked as it is inside the laundry room but it was recommended that this should be reviewed to reduce the risk to residents if the laundry door was inadvertently left unlocked. Sapling DS0000038846.V347085.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the numbers and skill mix of staff and they are in safe hands. Recruitment arrangements continue to improve but more work needs to be done on training. EVIDENCE: There are two staff on duty throughout the day and on the day of the inspection this was sufficient to meet residents care needs and to keep the home clean, and for the residents meals to be prepared. Staff did find some time in the afternoon to encourage residents to take part in activities but once the arrangements for activities have been reviewed as recommended, more staff hours may be necessary. There is a rota in place and staff were clear who was in charge. No domestic staff are currently employed. There are currently 12 staff employed at the home and the owner confirmed that four are trained nurses and four others have an NVQ Level 2. One other staff member is currently working towards an NVQ Level 2. The home therefore exceeds the 50 minimum number of trained staff recommended under Standard 28. There is now a recruitement policy in place and a copy of staff terms and conditions was shown to the inspector. One staff member interviewed Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 18 confirmed she had a copy at home. Two staff files were checked and showed that recruitment records continue to improve at this home. Both files had application forms, photographic ID, and CRB and pova checks. Both also had a full employment history. The owner is going through past recruitment records to ensure all staff have the relevant information on file, as set down in Schedule 2 of the Care Homes Regulations 2002. One of the two files checked had a reference from a friend/neighbour which is not acceptable. A Requirement will be made, with a time limit, for completing the work on retrospectively checking recruitment files to ensure they each have the correct information. There are potentially up to 16 training courses available to staff via the home, most of these outsourced, and certificates were kept on file. There is also a list in each persons file regarding the courses already taken. There have been improvements since the last inspection in relation to training, for example in relation to infection control training - 2 out of 3 training files checked showed staff had now done this course. Some specialist training has been given in relation to the specialist needs of residents, for example with regard to dementia. However, there is as yet no central list of what courses staff have done, nor when refreshers are due. The manual handling training is now also outsourced and though three staff files checked showed all three had completed the training, the certificates said they were only valid for one year and all three ran out in August. The Requirement made at the last inspection will therefore be repeated. Sapling DS0000038846.V347085.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. This home continues to be run without a registered manager. Arrangements for quality assurance continue to improve though more work needs to be done. Financial arrangements for resident’s monies are clearly documented. Health and safety arrangements continue to improve but more work needs to be done. EVIDENCE: There is currently no registered manager at this home and it is being managed by a deputy manager, and being overseen by the owner who is also the registered manager at one of the sister homes further down the road. Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 20 He stated that he has advertised but has had no suitable applicants and is now considering applying himself. He was advised to contact the south east registration team to discuss this further. There are clear lines of accountability within the home with all those spoken to being clear about who had overall responsibility for example for medication, and for health and safety. The Requirement to appoint a Registered Manager will be repeated. There is a policy and a system in place for monitoring the quality of the service including Regulation 26 visits every month by the owner. A folder is kept containing other monitoring such as monthly health and safety checks and the annual legionella checks. Resident’s meetings are held monthly and there are regular reviews of residents care – one resident is currently having a full review every three months. However, there is no annual development plan and it is not clear how the home is meeting other aspects of this Standard including 33.3-33.7. The owner was asked to review current arrangements in line with Standard 33. No residents at this home are able to manage their own finances. All residents are clients of the local authority and, in the absence of anyone willing and able to manage their finances, the owner said the local authority has asked him to do this via the Court of Protection. One resident’s file was checked and there was a letter on file from a social services care manager asking the Public Guardianship office to send an application pack for the owner. The owner said that where he does have responsibility for a resident’s finances, the books are checked periodically by an auditor from the Court of Protection. He said from October 2007 he will also get his accountant to independently audit these records. There is a health and safety policy in place and one staff member has been given responsibility for health and safety including the monthly audit and for risk assessments. The owner said the environmental health officer visited in 2006 and made no recommendations - the report could not be found on the day of the inspection, but the owner said the next visit was to be in two years.There is an annual legionella safety check on file and the deputy manager said shower heads were flushed though weekly. However, there was no policy in place and it was not clear how the home were protecting against legionella between annual checks. The owner was advised to contact the Health and Safety Executive or use their website to obtain the booklet and advice on managing legionella safety in care homes. The other shortfalls under health and safety including risk assessments and manual handling training, and the cleaning cupboard which was not locked, are discussed earlier in this report. It was also noted that several toilet seats in resident’s rooms were loose and one was completely broken. The owner began dealing with this when he arrived at the home. Sapling DS0000038846.V347085.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 22 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(2)(b) (c) Requirement Care plans and risk assessments must be reviewed and updated monthly to promote good practice and safeguard the welfare of service users. (Partially met from 01/07/06) Residents must have their needs assessed and documented in relation to falls and moving and handling, and subsequent risk assessments must be available to staff who support them. The policy of not locking the cleaning cupboard inside the laundry must be reviewed as discussed under Standard 19. There must be a written policy in place for staff in relation to accepting gifts. Staff files must contain all the necessary information set down in Schedule 2 of the Care Homes Regulations 2001 (as amended). The work to ensure this information is sought retrospectively for files were there are shortfalls must be completed in a timely fashion. The registered person must DS0000038846.V347085.R01.S.doc Timescale for action 30/11/07 2. OP7 13(4) (a)(c) 06/11/07 3. OP19 13(4) (a)(c) 13(6) 19 06/11/07 4. 5. OP18 OP29 06/11/07 30/11/07 6. Sapling OP30 18(c )(i) 30/11/07 Page 23 Version 5.2 7. OP31 8 8. OP38 13(4) (a)(b)(c) ensure staff training records are up to date and that all staff are trained for the work they are asked to perform. (Partially met from 01/08/06). The registered person must ensure an application for registration as manager is submitted to the CSCI to safeguard the interests and welfare of service users. (Not met from 01/09/06) The arrangements for the prevention of legionella must be reviewed and advice sought as discussed during the inspection. 01/12/07 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP16 Good Practice Recommendations Activity plans should be reviewed to ensure residents have sufficient stimulation throughout the week, and more opportunities to take part in meaningful activities. The up-dated complaints procedure, with the latest CSCI address, should be circulated to all stakeholders, as one person connected with the home stated they did not know how to make a complaint. The new Surrey County Council Contact Centre number should be added to the protection of vulnerable adults policy where all new reports must be made in the first instance. It is recommended that an occupational therapist’s opinion be sought in relation to the ramp outside the conservatory as a handrail may need to be fitted for added safety. It is recommended that the home reviews current quality assurance systems to ensure they address each aspect of Standard 33, especially 33.3-33.7. 3. OP18 4. 5. OP19 OP33 Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Sapling DS0000038846.V347085.R01.S.doc Version 5.2 Page 25 - 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!