Inspection on 07/02/06 for Searchlight Workshops - Webb House

This inspection was carried out on 7th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Searchlight Workshops - Webb... 30/07/07

Searchlight Workshops - Webb... 15/06/06

Searchlight Workshops - Webb... 19/07/05

Searchlight Workshops - Webb... 18/01/05

Searchlight Workshops - Webb... 17/08/04

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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 Searchlight Workshops - Webb House Claremont Road Mount Pleasant Newhaven East Sussex BN9 0NQ Lead Inspector Jennie Williams Unannounced Inspection 7th February 2006 10:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 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. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Searchlight Workshops - Webb House Address Claremont Road Mount Pleasant Newhaven East Sussex BN9 0NQ 01273 514007 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) Searchlight Workshops vacant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (6), Physical disability (16) of places Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That the maximum number of service users to be accommodated is twenty-two (22). That a maximum of six (6) service users accommodated must be older people, aged sixty-five (65) or over on admission. That a maximum of sixteen (16) service users accommodated will have a physical disability and be aged over fifty-five (55) on admission. That service users with a physical disability may also have a mild learning disability. 19th July 2005 Date of last inspection Brief Description of the Service: Webb House is a care home registered to provide accommodation for a maximum of 22 residents. Six places are registered for older people, aged 65 years or over on admission and sixteen places are registered for people with a physical disability who may also have a mild learning disability and must be aged 55 years or over on admission. Webb House is one of three homes within the Searchlight Workshop group located at the one site. The home is situated on the top of a hill on the outskirts of Newhaven. There is a mini bus available at the home. There are local amenities and access to bus routes at the bottom of the hill. All rooms are for single occupancy and are located over two floors. There is a passenger shaft lift available to assist residents to access all areas of the home. There is a workshop on the site available to residents and others within the community. A variety of crafts/activities are offered at the workshop. A social club is run on site and this opens a couple of evenings a week. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Webb House will be referred to as ‘residents’. This unannounced inspection took place over seven hours on the 7 February 2006. This inspection was facilitated by the acting manager. Care plans were spot-checked. Medication procedures and accident/incident reports were inspected. Staff files were inspected. Residents were spoken with throughout the inspection process and the inspector spoke with a visiting health professional. The environment was spot-checked along with some individual rooms. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection report of 19 July 2005. There were 21 residents residing at the home on the day of inspection. All have a physical disability. What the service does well: What has improved since the last inspection? The provision of meals has improved since the last inspection. The new care plan format has been implemented for all residents, along with a more structured key worker system that residents were finding of benefit. The recruitment procedure is more robust and a quality assurance and quality monitoring system has been developed and implemented. Staff now receive regular supervision. Work has been done to promote the health, safety and welfare of residents and staff as required from the last inspection. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 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 Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6 The home has information available to prospective residents and their representatives to make an informed decision if the home is suitable for their needs. Standard 6 is not applicable, as the home does not have dedicated accommodation to provide intermediate care. EVIDENCE: The Statement of Purpose and Service User Guide has been amended to reflect recent changes in management, as required from the last inspection. A copy of this is available at the entrance to the home, along with a copy of the most recent inspection. Residents have signed to say that they have read and understood the Service User Guide. The acting manager will undertake the pre assessment of all prospective residents. Information is also obtained from other health professionals wherever applicable. There had been one new admission since the last inspection. Prospective residents/relatives are encouraged to visit the home prior to admission. The home does not have dedicated accommodation to provide intermediate care, but does provide respite if there is a place available. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Care plans provide staff with suitable information on the assessed needs of the individuals. Medication procedures need to be greatly improved to safeguard residents. Residents’ privacy and dignity are respected. EVIDENCE: All residents care plans have been completed onto the new format. These documents provide clear guidance for staff about the assessed needs of the individual. The acting manager has implemented daily diaries for all individuals and a structured key worker system. Residents have found the key worker system of benefit. It will be the key workers responsibility to keep these documents up to date. It was confirmed that care plans are reviewed with the residents. There is structured time for key workers to spend one to one time with their allocated residents. The acting manager confirmed that care plans for residents under 65 years of age would be reviewed every three months. It was discussed with the acting manager that care plans should be a working document and must be reviewed on a monthly basis or earlier if the needs of an individual changes. The home in inspected under Older People standards. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 10 Nursing care is not provided at this home. District nurses will visit the home if any individual requires nursing input. The district nurses notes are kept within the office to ensure that staff at the home are spoken with and the home is aware that a visit has been undertaken. The acting manager confirmed that reviewing the risk assessments is her next task. It was confirmed that they have not been reviewed as required from the last inspection. This is an outstanding requirement. All assessments forms are being signed and dated as required from the last inspection. Residents’ health needs are being met with good support from health professionals within the community. A health professional from the Neurological Multidisciplinary Community Team was spoken with on the day of the inspection, who was very complimentary about the care provided at the home. One comment was ‘one of the best places to work with’. They confirmed that the staff were aware of an individual’s needs. They confirmed that staff received additional training on specialist needs for the recent new admission. There is also provision of massages for those residents requiring/wanting this alternative therapy. An external qualified masseuse undertakes massages. The home has implemented behaviour charts for those residents that may on occasion be disruptive and demonstrate signs of mental health issues. The acting manager will access assistance from the mental health team when required. These charts have been implemented following a requirement made at the last inspection. The managers from the three homes undertake weekly medication audits for each other. Although there is an internal monitoring system in place, there continues to remain shortfalls in the medication process. On arrival at the home, the medication trolley was observed to be unlocked. Although medication was not stored in here, there were tablets that had been administered into a ‘pot’, with no indication what they were or whom they were for. The Inspector asked the acting manager to address this immediately. It was confirmed that these had been dispensed into a ‘pot’ as the individual will often get up later. This practice is not suitable and must be stopped. There were medications that had been administered and not signed for and medications signed for and not administered. Handwritten MAR charts were not double signed as recommended from the last inspection. It was made an immediate requirement that a clear record of medication administration is maintained. There were some residents that self medicate. It was discussed with the acting manager the importance of ensuring these individuals store their Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 11 medication safely and the risk assessments are updated regularly. These risk assessments had not been reviewed for two years. There are proposals to convert an area into a medication storage and administration area. This will provide staff with more room to assist in organising the medications and have better conditions in which to deal with medication procedures. Residents spoken to felt that their privacy and dignity are respected. Staff were observed to have a good professional rapport with residents. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 Residents are provided with opportunities to participate in activities that are within their interests and capabilities. Visitors are welcomed at the home. The provision of meals has improved. EVIDENCE: Residents were overall satisfied with the activities provided at the home. There is a workshop on site that was observed to be well used. There is a social club that runs a couple of nights during the week that residents may join. This is also located at the same site as the home. An arts club has also been implemented one day a week. Visitors are welcomed at the home. Residents are encouraged to maintain contact with friends/family and to be involved in the local community. There is a visitor’s book at the entrance of the home that all people must sign when entering and leaving the home. Residents commented that the provision of meals is improving. There has been a lot of work done by the organisation to improve this service. Some dishes were commented on being ‘exotic’ and some residents did not understand what food was being offered. It has been recommended that the menu provide a clear description of what is included in the recipe. It has also been recommended that a notice board be placed in the dining room stating what food is being offered. Some residents stated that they get confused and Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 13 cannot remember what they have ordered, as they do the menus one week in advance. Comments regarding the provision of food varied from ‘improving’ to ‘excellent’. Another food survey was being undertaken with residents during the week of the inspection to obtain further feedback. It was confirmed that during the work of revamping the menus, the nutritional value and needs of residents are being included. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 There is suitable information provided to enable people involved with the home to make a complaint. There are procedures in place to deal with allegations of abuse. EVIDENCE: There have been no complaints made to the home or directly to the CSCI since the last inspection. There is a suitable complaints procedure in place. Staff receive adult protection training and it was confirmed that there are procedures in place for staff to follow in the event of an allegation being made. The content of this procedure was not read. It is recommended that the acting manager undertake a refresher course on the Protection of Vulnerable Adults (POVA) with the local authority. Correct procedures to follow were discussed on the day of the inspection. The home has obtained another copy of the East Sussex Multi-Agency Guidelines for POVA as recommended at the last inspection. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 & 26 The location of the home provides opportunities for residents and visitors to access local amenities and transport. Residents live in an environment that suits their needs. EVIDENCE: Webb House is one of three homes within the Searchlight Workshop group located at the one site. The home is situated on the top of a hill on the outskirts of Newhaven. There is a mini bus available at the home. There are local amenities and access to bus routes at the bottom of the hill. All rooms are for single occupancy and are located over two floors. There is a passenger shaft lift available to assist residents to access all areas of the home. There are suitable communal, toilet and assisted bathing facilities provided at the home to meet the needs of residents. There has been a grab rail placed in the lower ground floor corridor as recommended at the last inspection. Residents confirmed that this has been of benefit to them. There is work being done to have the home assessed by an Occupational Therapist, as recommended at the last inspection. This remains an outstanding recommendation. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 16 Residents spoken with were happy with their rooms. Some were seen to be personalised to reflect the individual’s choice and personality. Residents are only permitted to smoke in designated areas. There was evidence that a resident is smoking in their own room. There were numerous burn holes in the carpet and cigarette butts were noted to be in a plastic bag in a plastic bin. It was made an immediate requirement that a risk assessment be undertaken and for staff to implement steps to monitor the number of burn holes. The home has been addressing this issue with the resident. Laundry is done centrally for all three homes located at the one site and is located away from the home and any areas where food is stored, prepared, cooked or eaten. The home was clean and free from offensive odours on the day of the inspection. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The number and skill mix of staff on duty is meeting residents’ needs. Staff are trained and competent to do their jobs. The robust recruitment procedures safeguard residents. EVIDENCE: Residents were complimentary about the staff working at the home. Residents spoken with confirmed that they felt there were enough staff on duty. The only time there may be a shortage of staff was during periods of staff illness. The home is currently having to use agency staff for about three to four shifts per week. It was discussed with the acting manager that written confirmation is obtained from the agency to ensure that the staff provided has had relevant recruitment checks undertaken. The same staff is provided by the agency to ensure continuity of care. The home currently has one part time vacancy for a carer. A manager of another home within Searchlight Workshops maintains the training schedules for all staff within the three homes. She will send training schedules to the acting manager to notify the staff when training is being provided. Staff are kept up to date with all mandatory training. New staff are provided with induction files that must be completed. It was confirmed that these cover all Foundation Standards and comply with the TOPSS specifications. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 18 The home is working towards meeting the 50 ratio of NVQ level 2 qualified staff. One staff member who had NVQ level 3 has left employment since the last inspection. There are four staff currently undertaking their NVQ level 2 training and two staff doing NVQ level 3 studies. This has not been reflected as an outstanding requirement, as there is evidence the home is working towards the required ratio. This will be reassessed at the next inspection. Staff files inspected demonstrated that work has been done to ensure staff files comply with Schedule 2, as required from the last inspection. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35, 36 & 38 The home is run in the best interest of residents. Additional work needs to be undertaken to continue to promote the health, safety and welfare of residents and staff. EVIDENCE: The acting manager has been in post since June 2005. She has worked within the care industry for a period of time in a variety of roles, predominantly working with people that have learning disabilities. The acting manager should be complimented on the positive changes that have been implemented at the home. The acting manager achieved NVQ level 3 qualifications nine years ago. She is currently undertaking NVQ level 4 in Health and Social Care. She has undertaken risk assessment training. The home has commenced an effective quality assurance and quality monitoring system. Surveys have been undertaken for residents, relatives and Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 20 health professionals. This has proved a positive response. There was evidence that feedback had been sought from GP’s, Dentist, District Nurses and Social Workers. There is a designated person within Searchlight Workshops who has taken on the responsibility of implementing the quality assurance and quality monitoring on an annual basis. The organisation continues to obtain individual bank accounts for the residents as required from previous inspections. Residents have been provided with lockable facilities within their own rooms for safe storage of monies/belongings. Residents are assisted in procedures for managing and budgeting their own finances. The home has amended the Gifts to Staff policy, as highlighted at inspection at another of the homes within the Searchlight Workshop group. This has not been reflected as an outstanding requirement as the home is working towards ensuring all residents are provided with their own bank accounts. This will be reassessed at the next inspection. The acting manager has implemented a timetable to ensure that all staff receive supervision at least every three months. It was confirmed that records are kept of these supervision sessions. This has been implemented following a requirement made at the last inspection. Trustees of the organisation undertake monthly unannounced visits to the home to monitor practices and provides a report to the home and CSCI. There are clear roles and responsibilities within the organisation. There is appropriate insurance in place. The financial viability of the home was not inspected. Searchlight Workshops have given no cause of concern regarding financial viability to date. A manager of one of the other homes is also the designated health and safety officer. The acting manager confirmed that all relevant checks are undertaken and up to date. Staff receive all mandatory training relating to health and safety. It was confirmed that there is now a designated first aider on every shift. There remain shortfalls in the documentation of accidents. One report identified that a resident had a fall and a cold compress was applied. There was no indication what injury was sustained or where the cold compress required to be applied. Clear documentation of accidents and incidents remains an outstanding requirement. Some radiators remain unguarded. The home needs to ensure that these are guarded or have guaranteed low temperature surfaces. The home had undergone an inspection for the fire safety procedures the week prior to the inspection. This report was unavailable to read, but the acting manager confirmed that there were no problems identified from this Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 21 inspection. Staff had recently been provided with fire training from an external company and a fire drill was undertaken about three months ago. Any other shortfalls in the health, safety and welfare of residents have been highlighted in the relevant sections of the report. Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X 2 3 X 2 Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 23 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. 2. Standard OP7 OP7 Regulation 15 13.4 Requirement That care plans are reviewed at least monthly or earlier if the needs of an individual changes. That risk assessments be reviewed when care plans are reviewed. (Outstanding from previous two inspection) That all medications are signed for at the time of administration or reasons given why it is omitted. (Timescale 19.07.05 not met, immediate requirement) That an accurate record of medication administered is kept. All medication signed for must be administered. (Timescale 19.07.05 not met, immediate requirement) That medication is only dispensed at the time of administration. (Immediate action required on day of inspection.) To ensure any self-medication in the home is managed under a risk assessment basis and kept under review. Timescale for action 31/03/06 31/03/06 3. OP9 13.2 07/02/06 4. OP9 13.2 07/02/06 5. OP9 13.2 07/02/06 6. OP9 13.2 31/03/06 Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 24 7. 8. OP25 OP29 13.4 18 & 19 9. OP38 Schedule 4 (12) 10. OP38 13.4 That radiators are guarded or have guaranteed low temperature surfaces. That the home receives written confirmation that all agency staff working at the home have had all relevant recruitment procedures undertaken. That documentation of accidents/incidents be improved and that action identified to be taken is evidenced. (Timescale 30.09.05 not met) That steps are implemented to monitor the number of burn holes in a smokers room and a risk assessment be implemented. (Immediate requirement) 30/04/06 31/03/06 31/03/06 08/02/06 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. Refer to Standard OP9 Good Practice Recommendations That hand written MAR charts are double-checked by two staff who are trained in medication administration. Any changes written on MAR charts must be signed by the person amending it. (Outstanding recommendation) That the menu provides a clear description of what is included in the recipe. That a menu board is predominantly displayed to provide service users with information on what meals are being provided for the day. That the acting manager undertakes a refresher course on POVA. That the home be assessed by a qualified Occupational Therapist. (Outstanding recommendation) That the smoking policy be reiterated to all residents. 2. 3. 4. 5. 6. OP15 OP15 OP18 OP22 OP38 Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Searchlight Workshops - Webb House DS0000059528.V267158.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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