Inspection on 10/08/06 for Scope - The Hollies

This inspection was carried out on 10th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Scope - The Hollies 10/05/07

Scope - The Hollies 06/12/05

Scope - The Hollies 14/06/05

Scope - The Hollies 21/02/05

Scope - The Hollies 18/08/04

Scope - The Hollies 22/02/04

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

CARE HOME ADULTS 18-65 Scope 1 ,2 and 3 The Hollies Halton Brook Avenue Halton Brook Runcorn Cheshire WA7 2FU Lead Inspector Maureen Brown Key Unannounced Inspection 10th August 2006 10:30 Scope DS0000005179.V292118.R01.S.doc Version 5.1 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 Scope DS0000005179.V292118.R01.S.doc Version 5.1 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 Adults 18-65. 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. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Scope Address 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) 1 ,2 and 3 The Hollies Halton Brook Avenue Halton Brook Runcorn Cheshire WA7 2FU 01928 590168 SCOPE Martyn Swindell Care Home 9 Category(ies) of Physical disability (9) registration, with number of places Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 9 service users in the category of PD (Physical disability) 6th December 2005 Date of last inspection Brief Description of the Service: The premises of 1 - 3 The Hollies are owned by Liverpool Housing Trust, and are managed by Scope. The home is located in the Halton Brook area of Runcorn with easy access to local amenities and facilities. The Home is comprised of three bungalows accommodating nine service users who are physically disabled. Each bungalow provides three bedrooms and a shared kitchen/dining area, lounge, bathroom, separate shower room, a utility room and brick built outdoor shed. The fees at The Hollies are between £36,128.00 and £48,151.00. Optional extras include CD’s, Videos, DVD’s, holidays, magazines, decoration of own bedroom, clothing, toiletries and hairdressing. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was carried out on 10th August 2006. The total time on site was five hours ten minutes. The inspector spent half an hour planning the inspection by reviewing the previous inspection report and the service history. The site visit included a tour of the communal areas and some bedrooms, inspection of records and discussions with residents, the registered manager and the support workers on duty. Twenty-seven out of forty-three standards were assessed and some were met. All the key standards were assessed. Nine service users, nine relatives, two visiting professionals and four GP comment cards were received. Feedback was given to the registered manager at the end of the site visit. What the service does well: What has improved since the last inspection? Completion of care plans had improved. The residents and their carers are now consulted regarding the care plan and the resident or carer had signed these. The service user care plan was now reviewed on a monthly basis. Risk assessments were up to date and daily record sheets were now only completed in black or blue ink. The standard of the furnishings had improved in Bungalow Three with the replacement of the freezer. Staff supervision had been brought up to date and annual staff appraisals had been completed. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 6 To show that residents are receiving care from staff that have been properly vetted all pre-employment checks had now been completed. Residents’ views had been sought from surveys and from conversations with them. It is expected that the quality assurance process will be completed on an annual basis. New laminate flooring had been provided in two bedrooms and a lounge. Redecoration of bedrooms is on a rolling programme. 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. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. Sufficient information is provided for residents to make a decision about moving into the home. EVIDENCE: The statement of purpose and service user guide was available to service users and prospective service users. No changes had taken place since the last inspection. These documents were last reviewed in May 2006. A copy was available in each service users bedroom. During discussions with staff it was evident they were aware of service users needs. Within each service user file a pre-assessment document was available which detailed their needs. From the service users files it was noted that families confirmed their involvement in care planning and reviews. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. Residents and relatives were satisfied with the support they received from the manager and staff. EVIDENCE: Three out of nine service users files were examined. The inspector noted that new files had been provided for service users information. The file contained the care plan, risk assessments, daily record sheets, twenty-four hour care summary, reviews of care plans and contract. These files contained all the information necessary to ensure that service users needs are met. The care plans were well written and gave a clear picture of the support needed. A recommendation from the previous visit regarding service users or their families confirming their involvement in the care planning and review process had been completed. Other records seen relating to the service users included the social services reviews and terms and conditions of residence. All these documents were up to date with appropriate recordings. The daily records were very good and staff noted changes to service users, activities undertaken Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 10 and the details of visitors were also recorded. All files examined had up to date service user plan reviews. Service users confirmed that staff helped and supported them when they needed it, such as with personal care tasks and that staff “usually treat me well”, “Staff team is very friendly” and “the home is usually fresh and clean”. Observations made during the site visit included seeing staff knock on the bedroom door before entering and staff interactions with service users during the tour of the home. The staff were attentive to service users needs and helped them when required. The general atmosphere within the home was warm and friendly. Staff were also friendly towards visitors. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 & 17 Quality in this area outcome is adequate. This judgement was made using available evidence including a visit to this service. Residents’ were able to take part in a limited range of activities. Personal and family relationships were encouraged by the home and the staff team supported people with this. EVIDENCE: Each service user has three sessions a week at “lifestyles” provided by Scope. Activities include going to “Sutton Fields” community centre, bowling, going to the allotment, cooking, crafts and flower arranging. Other activities, which could be on an individual basis with staff or in small groups, included going out shopping locally and to local attractions. Service users commented, “I would like to go out more but they’re on not enough staff to spare”, “I would like to go out more if it could be arranged” and “not enough staff on at the weekends to go out with”. The visits from families and friends were recorded in the daily record sheets. These were seen during the site visit. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 12 Surveys from relatives reflected the following comments “were satisfied with the overall care provided”, “I would like my son/daughter to visit me more at home”, “the manager keeps me informed of what is going on at the Hollies” and “I am very pleased with the way my son/daughter is cared for”. Samples of menus were seen during the site visit. These showed a diet with a variety of meat, fish and cheese was provided to the service users. However the menu lacked a choice of fresh vegetables, fruit and desserts. On rare occasions vegetables were served. A recommendation was made with regard to using fresh vegetables on a regular basis. On occasions no menus were recorded and sometimes a resident refused lunch and dinner. No record to show extra drinks were given or any other action taken was available. A requirement was made accordingly. The main meal was eaten in the evenings as some service users were out and about during the day. One service user said “the meals are good here, plenty of variety and we choose the menus for the week. If you don’t like what is on the menu then an alternative meal is offered”. During the tour of the bungalows fresh fruit was seen available in the kitchen areas and yogurts were available within the fridge. Following a requirement made during the previous visit the freezer in bungalow 3 had been replaced. See requirement No. 1 and recommendation No. 1. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this area outcome is adequate. This judgement was made using available evidence including a visit to this service. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: Each service user had a visiting professional sheet that detailed visits made regarding all areas of health care needs. The information included visits to GP, chiropodist, opticians, dentist and medical appointments. It was noted that although the chiropodist was expected to visit every three months, in reality this often did not happen. One service user had not seen the chiropodist for eight months and a recommendation was made regarding this. One relative commented, “My relatives nails are too long”. Annual checks for all service users for the dentist and optician were not evident. A requirement was made accordingly. Four GP comment cards were received and they stated “excellent care given”, “first class care given to the service users within the home” and all the GPs commented “they were satisfied with the overall care provided”. A social worker commented “I have always found the staff and manager helpful and professional and I am satisfied that I would be contacted if there were any difficulties relating to my client.” Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 14 A visiting nurse also commented “I am satisfied with the overall care provided to my patient”. The medication system is kept in a locked steel cupboard within each bungalow. This was located within the bathroom. A monitored dosage system was used and all medication was stored appropriately. The medication administration sheets seen were signed and up to date. Drugs are returned on a monthly basis. Staff are trained in medication awareness. Staff files examined showed medication training undertaken. See requirement No.2 and recommendation No.2. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this area outcome is poor. This judgement was made using available evidence including a visit to this service. Residents and relatives were satisfied with the support they received from the manager and staff. Clear policies were in place to ensure that residents were protected from abuse, neglect and self-harm, however these had not been used and had therefore put service users at risk. EVIDENCE: On examination of two staff files it was evident that recent Protection Of Vulnerable Adults training had taken place. On discussions with the staff team they were able to explain what abuse was and that they would let the manager know if they were concerned about any service users. Out of eighteen staff, sixteen had received Protection Of Vulnerable Adults training. However, the requirement made during the last inspection remains outstanding, in that, all staff must receive this training. The manager was able to demonstrate his knowledge of Halton’s “No Secrets” and Scopes Abuse Policy. These were available for the staff to read. The manager and staff confirmed that they had received awareness training in Protection Of Vulnerable Adults. Scopes policy on Adult Protection was dated November 2002 and this should be reviewed. A requirement was made accordingly. At this time three adult protection issues are being investigated at this home. Although sufficient documentation was available to the manager and staff for guidance, these current cases were not reported using this guidance, leading to a significant delay before social services adult protection team were notified. This potentially left the service users at significant risk within the home. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 16 It was noted that the Adult Protection training did not follow the “No Secrets” guidance fully and therefore this must be reassessed to ensure the relevant guidance is followed and cascaded to the staff team. The complaints procedure was seen and this contained details of the Commission and the ombudsman. The home used a complaint book, which detailed two complaints made since the last visit. Both of these had been resolved to the complainant’s satisfaction. Scopes complaint form and procedure was available but not used. The manager stated that senior management at Scope had raised this and the registered manager had been instructed to use this documentation for all complaints. The inspector also agreed that this would improve the documentation of complaints. A recommendation was made. CSCI had not received any complaints since the last inspection. Service users spoken with confirmed they would contact the manager if they had any problems. This was also confirmed through service user surveys and relative’s surveys. See requirements Nos. 3 & 4 and recommendation No. 3. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. The home provides a clean and comfortable environment for the people to live in. EVIDENCE: A full tour of the communal areas and a selection of bedrooms were seen. The home was found to be fresh, clean and odour free. Bedrooms had been personalised by the service users with their own furniture, pictures and mementoes. Two service users were in their bedrooms during the tour. Service users confirmed that they liked their bedrooms and that the “home was nice”. Other comments included “I like living here” and “it is my home”. The home was light, airy and was warm. On discussions with service users it was confirmed that the home was warm enough for them. A new freezer had been provided in Bungalow 3 following a requirement made during the last visit. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 18 New laminate flooring in two bedrooms and lounge had been completed and redecoration of bedrooms was ongoing. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. Records were maintained in a satisfactory manner and service users are protected by the homes recruitment policy and practices. EVIDENCE: The staff rotas showed the staff on duty over the week. This appeared to meet the needs of the service users. Service users confirmed that enough staff were around to help them and observations made during the site visit showed staff were attentive to service users needs. Three staff files were examined. These were well documented and had all preemployment checks in place. A previous requirement regarding preemployment checks had been addressed. Following a requirement at the previous visit a range of training had been undertaken in relation to the staff member’s role. However, this remains outstanding, as not all staff had undertaken mandatory training, such as food hygiene, moving and handling, health and safety, risk assessments, fire awareness and first aid. All records seen had up to date appraisals (a previous requirement regarding appraisals had been met) and the supervision log clearly noted when these had Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 20 taken place. Supervision records were seen and all staff had received supervision during June and July 2006. A requirement had been made during the last visit regarding supervision, which was met, however a recommendation for this process to continue was made. Staff meetings take place on a regular basis usually every month. The last meeting was held on 28/6/06 and issues discussed included service users, staff, health and safety. Also discussed were documentation, communication and medication. The previous meeting was held on 24/5/06. It was noted that the meetings tend to be held at the same time or day for each session and that less than 50 of staff attend. A recommendation was made that the day and time of these meetings be examined to ensure the attendance of the maximum numbers of staff. Staff had undertaken training on NVQ level II & III, medication, fire training, health and safety, risk assessments, colostomy and stoma care, adult protection, moving and handling and food hygiene. Out of eighteen staff, ten staff had achieved NVQ level II and both the seniors were NVQ assessors. See requirement Nos. 5 & 6 and recommendations Nos. 4 & 5. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42 Quality in this area outcome is adequate. This judgement was made using available evidence including a visit to this service. The health, safety and welfare of the service users are protected. The views of service users are obtained and used to influence the running of the home. Fully supervised staff support Service users. The manager does not provide clear leadership to the staff team. EVIDENCE: The manager does not provide clear leadership to the staff team. Day to day supervision appears to be adequate, however reporting of adult protection issues was poor and significantly put service users at risk. On discussion with the manager he stated that supervision with his manager did not take place regularly and that no records were kept. He stated that his last meeting with her had been some time ago at his appraisal in June 2006. He said that his manager was very busy but that he could contact her by phone. He admitted that he tended to seek advice and support from the other managers generally. A requirement was made regarding keeping of supervision notes and frequency of supervision sessions. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 22 A selection of policies and procedures were examined. These were up to date. A previous requirement regarding keeping records up to date had been addressed. A quality assurance process was in place. Discussions regarding this were held with the manager. The process was undertaken in January 2006. However, an analysis of this information had not been produced or circulated to service users, staff, families, CSCI or any other interested parties. A requirement was made. Regular house meetings were held and the last one was dated 13th July 2006 with records kept. The previous meeting was held on 26/5/06. The manager stated that he discusses the outcomes of meetings with all service users who do not attend. It was noted that five or six service users usually attended. Safe working practices were in place. Up to date fire safety checks on the fire system was in place. A weekly sound test of the system was recorded. Fire doors and emergency lights were checked on a monthly basis and staff had received fire safety awareness training during the last two months. Up to date gas safety and electrical wiring safety certificates were available. All wheelchairs and hoists were regularly serviced. Portable Appliance Testing had been carried out in November 2005. The maintenance book was seen. It recorded all repairs etc that the staff had noted. The manager stated that routine repairs were carried out as required and emergency repairs were carried out the same or the next day. Other repairs were unusually completed within three days. The accident record book was seen. All copies are kept separately to the book with only the seniors and manager having access. This is in line with the Data Protection Act. The manager is the Designated Adult Protection Advisor, he also has the BTEC in Management Studies and ICSC (in service course for social care). He had recently completed the Registered Managers Award. See requirement No. 7. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 2 X 3 3 X Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 24 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 YA17 Regulation 16 Requirement The registered person must ensure that menus are always recorded and that if a meal is refused by a resident then action taken to be record. The registered person must ensure that annual health checks are carried out for all service users. The registered person must ensure that all staff receive training in Adult protection from Abuse. Timescale of 31/03/06 not met. The registered person must ensure that Scopes policy on Abuse dated November 2002 be reviewed. The registered person must ensure that all staff members undertake all areas of mandatory training including moving and handling, food hygiene, fire awareness, first aid, health and safety and risk assessment. Timescale of 31/03/06 not met. DS0000005179.V292118.R01.S.doc Timescale for action 31/10/06 2. YA19 13 31/10/06 3. YA23 13(6) 31/10/06 4. YA23 13 31/10/06 5. YA35 18 31/10/06 Scope Version 5.1 Page 25 6. YA36 18 7. YA39 24 The registered person must ensure that supervision notes are kept of the sessions between the registered manager and service manager and regular sessions are undertaken. The registered person must ensure that the quality assurance process is shared with residents, families, other interested parties and the Commission. 31/10/06 31/10/06 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. 4. 5. Refer to Standard YA17 YA19 YA23 YA36 YA36 Good Practice Recommendations The registered person should ensure that more variety of fresh vegetables, fruit and deserts are available and recorded on the menu plans. The registered person should ensure that chiropodists’ visits are monitored to ensure regular contact with service users. The registered person should ensure that Scopes complaint form be used. The registered person should ensure that supervision sessions continue to be completed. The registered person should consider the times and days of staff meetings to ensure the maximum attendance of the staff team. Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Scope DS0000005179.V292118.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!