CARE HOMES FOR OLDER PEOPLE
Sheldon House Sea View Road Falmouth Cornwall TR11 4EF Lead Inspector
Paul Freeman Announced Inspection 20th March 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sheldon House DS0000008894.V276749.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 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. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Sheldon House Address Sea View Road Falmouth Cornwall TR11 4EF 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) 01326 313411 01326 317902 Mr Charles Barry Libby Mrs Anne Louise Libby, Mr Darren Libby Mrs Doreen Ann Peters Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (34) Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 29th September 2005 Brief Description of the Service: Sheldon House is a long established care home and is registered to provide nursing care for up to 34 people who experience dementia or enduring mental illness. The current owners have run the home since November 2000 and have ambitious plans to redevelop the site and create a purpose built care home. The current accommodation is a former hotel that was initially converted around 1994 and since then has undergone further structural changes. It is located on a quiet residential road close to the town and beaches of Falmouth. It is easily accessible on foot and by transport from the town and this results in frequent visits to the home by relatives and friends. There is also car-parking facilities at the front of the home. The current accommodation is provided over three floors and is accessible to people who experience a disability given two shaft lifts are provided. The building is not the best design to provide the care and support required by residents and the layout does not easily lend itself to meeting the needs of residents. The bedrooms are for both single and shared occupancy and three communal areas are provided on the ground floor. A dining room has recently been established on the ground floor that is also used as a quiet area and for activities. It is therefore constructive that positive plans have been developed to provide quality accommodation that will address the current shortfalls. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned announced inspection took place on 20 March 2006. The purpose of the inspection was to inspect some of the core standards. Therefore some of the key national minimum standards that were considered include assessment and care planning, health and safety and staffing arrangements. The registered providers, residents and staff were consulted about the services and facilities provided. In addition the Inspector made a number of observations about the care and support provided to residents. The environment, records and documents were also considered. Before the inspection took place the providers sent written information to the Commission about the operation of the home. In addition three relatives also wrote to the Commission about their experiences and views of the care and support provided. A number of the residents have complex needs that require a systematic and structured approach. The nature of the residents needs is such that a high level of staff support and guidance is required to provide a safe and meaningful setting. In addition over the three floors there were also a number of vulnerable residents who were confined to their beds due to poor health. The providers have established a reputation for positively caring for individuals that are potentially volatile or have behaviours that challenge the care sector. Therefore a careful balance needs to be established to make sure that the needs of the user group are not compromised. The limitations of the environment do not assist the providers in meeting this goal. The requirements and recommendations set at the last inspection had been worked upon and the provider, staff and residents fully cooperated and were very helpful throughout the inspection period. What the service does well:
The staff at the home positively supports residents to be as independent as possible. This occurs in a manner that takes account of the residents’ skills and abilities and makes sure that residents are not placed at risk. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 6 It is clear the residents are treated with dignity and respect by the staff and that positive trusting relationships have been established. One relative commented, “there is a natural dignity and rapport with each resident”. The staff is also committed to offering residents every reasonable opportunity to exercise choice and have control over their lives. This happens in a manner that takes account of residents’ skills and makes sure their safety is not compromised. Residents are provided with a varied and nutritional diet that reflects their choices and preferences. One of the cooks regularly consults with residents to make sure the best possible menu is in place. The kitchen staff is also able to cater for special diets. A satisfactory complaints policy and procedure is in place and the providers are committed to resolving any concerns or complaints at the earliest opportunity. Appropriate arrangements are also in place to protect residents against abuse. Where allegations or concerns arise the matter is referred to the statutory agencies that coordinate any investigations that are required. The staff at the home has a wide range of skills and abilities and many are experienced in the social care sector. The staff is also provided with regular opportunities to develop their knowledge and skills and the providers are currently finalising a training programme for the staff group. This will also mean that each individual staff member has an individualised training plan. The staff is confidant they are appropriately supported and clearly there is a good team spirit. One relative said “I see nothing but friendly kindness and good humour”. A relative also commented upon the “high standards of care” provided. The home is well manager and the registered manager who commenced employment in September 2005 had made a positive impact. The manager has set an agenda to improve and develop the services and facilities. The staff clearly has confidence in the manager and commented upon the improvements that have occurred. The manager has also put in place appropriate arrangements to review the quality of the services and facilities provided and the findings will also be included in any plans to improve the services and facilities. What has improved since the last inspection?
The arrangements to assess the needs of prospective residents have significantly improved following the last inspection on 29 September 2005. Each prospective resident is assessed to make sure the services and facilities at the home are suitable to meet the individual’s needs and preferences.
Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 7 The prospective resident is included in the assessment process and the providers also consult their relatives or representatives. The views of any professionals’ involved with the individual are also taken into account. The assessment arrangements also give prospective residents and their relatives or representatives confidence it is a suitable setting for the person to reside. The care planning arrangements have also improved and better guidance, direction and information is provided to staff about the care and support each residents requires. Regular arrangements have also been established to regularly review the plans to make sure they accurately reflect the care and support each resident requires. The providers have developed the arrangements to store and administer prescribed medicines. Positive arrangements are now in place that promote good practise. The appointment of an activities coordinator has provided residents with a range of recreational opportunities at the home and in the local community. The activities offered reflect the interests and hobbies of residents and the providers are keen to expand and develop these opportunities. The providers have also established a rolling programme of redecoration and replacement and a number of areas and rooms in the home have been improved since the last inspection. The use of the communal space available had also been reviewed and a dedicated dining area has been established. This has improved the arrangements for residents. The providers have also worked hard to eliminate offensive smells that were evident in a number of areas at the last inspection. A significant impact has been achieved but further improvement is required in certain specific areas. The staffing arrangements have been reviewed and improved following the last inspection. The duty roster has been revised and staff and the providers said it had enhanced the staff ability to provide the care and support required. Staff deployment has also been improved to make sure that staff is in key locations during waking hours. This has also improved the residents’ access to staff whenever they require assistance. The providers said the arrangements continued to be under review and further adjustments would be made where required. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 8 The arrangements to assess and manage risks at the home are significantly better. This has resulted in the number of reported accidents and incidents significantly reducing. This has also resulted in improved guidance, direction and information to staff about the steps that are needed to minimise any risks or hazards. Further improvement is require in the quality of the information provided to staff. 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. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 9 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 Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 10 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): 3 and 6. Assessment arrangements continue to improve in order that the appropriate care and support can be provided that reflects the resident’s choice. EVIDENCE: The assessments of need arrangements for residents that had recently moved to the home were considered. It is evident the providers have made considerable progress to make sure the assessment arrangements were improved so that a clear picture could be obtained of the individuals needs, preferences and choices. The improved assessment arrangements also enables the providers to more effectively be satisfied the facilities and services are appropriate to meet the prospective residents needs. The arrangements also given confidence to the prospective residents and their relatives or representatives their needs will be met. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 11 Each prospective resident is invited to participate in the assessment process. In addition their relatives or representatives are consulted and the providers also obtain the views of any professionals involved with the person. Although the arrangements are more robust in certain instances they would benefit from more detailed information to make sure a comprehensive care plan can be established. This will also help to more effectively provide staff with the information and guidance they require. The home does not provide a dedicated intermediate care or rehabilitation service. However it is evident that staff provides support in a manner that promotes residents independence as far as possible. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 12 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, 9 and 10. The care planning arrangements continue to improve in order that staff are provided with adequate information, direction and guidance to meet residents needs and choices. Satisfactory arrangements are in place to store and administer medicines, which promote residents health. EVIDENCE: Each resident has a care plan and a number were sampled during the inspection. The providers stated that is the intention to continue the development of the care planning arrangements so the person centred model is established. This model is viewed as best practise for people who experience dementia or enduring mental illness. It is evident the care planning arrangements have been improved since the last inspection. The care plans detail the specific needs residents experience and provides staff with information, guidance and direction about the most appropriate ways to provide the care and support required. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 13 Some of the plans also provide pertinent information about the individual’s background and life experiences. This is an area the providers said needs to improve further. The staff said they found the plans to be informative and give better guidance about the individual and their needs. In certain instances the guidance to staff could be clearer and more detailed in order that the best possible picture of the care and support required is provided. It is also clear the care plans are regularly reviewed to make sure that changing needs are accounted for and that the most appropriate care is in place. It is not always clear who was involved in the review and different staff record the conclusion of each review in different places. It is recommended that this practises is standardised to make sure staff are clear about where to access up to date information. Following the last inspection the providers have improved the arrangements to store and administer medicines. The current arrangement consequently meet the standards required. Medicines are stored securely and safely and appropriate records are maintained. There are suitable arrangements to dispose of unwanted medicines and a satisfactory policy and procedure is in place to guide, direct and inform the staff. From observations it was evident that staff treat residents with dignity and respect and that positive and trusting relationship have been established between residents and staff. One relative commented, “there is a natural dignity and rapport with each resident”. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15. Residents are provided with a range of recreational opportunities that reflect their interests and offer a varied lifestyle. Residents are able to exercise choice and control over the lives as far as possible. Residents are provided with a varied and nutritional diet that reflects their preferences and choice. EVIDENCE: The providers have recently recruited a activities coordinator who works at the home each weekday. The coordinator has significantly broadened the social and recreational opportunities for residents at the home and in the local community. Therefore residents are having opportunities to experience a more varied and stimulating lifestyle. The coordinator continues to consult with residents and staff about the residents’ recreational choices and preferences. The providers stated they envisage the coordinator will act as a catalyst to improve and develop valued opportunities for residents. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 15 It is evident that residents get a great deal out of the improved arrangements and this highlights the importance of detailed information in the assessments of prospective residents about their social and recreational needs. The staff operates in a manner that encourages residents to have as much control and choice as possible over their lives. The improved assessment arrangements have assisted the staff to achieve this goal and further improvements will further enhance the approach staff takes. A varied and nutritional diet is in place and residents have a choice of the food they have at each mealtime. The menu reflects the choices and preferences of the residents and the cook regularly consults with residents to see if any further improvements can be made. In addition the menu is seasonally varied. The kitchen is well maintained and the equipment is regularly serviced. The kitchen was found to be clean and hygienic and appropriately staffed. Suitable health and safety measures were also evident. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Satisfactory arrangements are in place to deal with complaints and any allegations or concerns of abuse to residents. EVIDENCE: The Commission or the providers have not received any formal complaints following the last inspection. A suitable policy and procedure is in place for complaints and the providers are committed to dealing with any complaints or concerns expediently and in a satisfactory manner to all parties concerned. The arrangements to protect residents against abuse have been improved and developed. A satisfactory policy and procedure is in place and any concerns or allegations are reported to the statutory agencies for investigation. A rolling training programme about the protection of residents is in place for the staff and suitable advice, guidance and direction are provided to new staff during their induction programme. A suitable whistle blowing policy is also in place. This allows staff to report any concerns they have about abuse to a third party if they feel unable to inform the providers of the circumstances. This provides residents with additional protection against abuse. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 17 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 and 26. The layout of the building limits the providers ability to provide an environment that is user friendly, homely and comfortable. To address the shortfall plans have been established to build a new home on the same site. The providers are making concentrated efforts to make the environment as comfortable as possible for residents. The standards of cleanliness and hygiene continue to improve but further improvements are required in certain areas. This will make sure that residents are free from offensive odours. EVIDENCE: Following the last inspection the providers have taken steps to improve the environment for residents. This has resulted in establishing a programme of redecoration and replacement and it is evident the setting presents as more comfortable and homely for residents. The home is a three storey building with the communal areas located on the ground floor. The layout of the home has significant limitations in providing
Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 18 good quality services and facilities. This has been recognised by the providers and plans have been established to replace the current accommodation with a new building that will be purpose built. The providers have consulted with residents, their relatives or representatives and staff about the plans and it is hoped that building with commence at the earliest opportunity. It is planned the building will be undertaken in two phases to make sure that any disruption to residents is minimised. The providers are also aware the layout of the building does present certain limitations and challenges in creating and providing the homely and comfortable setting for residents. The current programme is designed to maximise the opportunities for improvement until a more suitable alternative is available. The providers have also reviewed the communal areas and created a designated dining area. Although there are certain space restrictions it has improved the facilities available to residents. The space is also utilised at other times by residents for a variety of reasons. The manager has also taken steps to improve the storage arrangements and the environment was less cluttered and more orderly. This has also resulted in minimising potential hazards to residents and staff. The providers have also taken steps to improve the hygiene and cleanliness at the home and this has reduced the occasions where offensive smells were previously evident. The providers are aware that offensive smells have not been completely eradicated and this is an area that requires further attention. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The staffing arrangements have been improved to make sure that resident’s needs are met in the best way possible. Further improvements need to be considered so that a clean and hygienic setting is provided. Staff is well trained and have a range of skills and experience in providing care and meeting residents needs. The recruitment process needs to be more robust to make sure residents are not inadvertently placed at risk. EVIDENCE: The providers have reviewed and improved the staffing arrangements to make sure that sufficient numbers of staff are on duty each day and night. This has resulted in additional staff on duty at peak times and a reorganisation of the duty roster to more effectively meet the needs of residents. Staff said they felt the new arrangements had improved their ability to provide the care and support required. The deployment of staff has also been improved to make sure that staff is in key locations during waking hours. This has also improved the residents’ access to staff whenever they require assistance. Additional senior carers have been appointed and a senior is on duty during all waking hours. The senior assists the person in charge to coordinate the work of the care staff.
Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 20 The staff said this had improved their efficiency and increased the support and guidance available. The providers said the arrangements continued to be under review and further adjustments would be made where required. The arrangements regarding the domestic staff continue to be under review given that currently all the staff is on duty for mornings only. The providers also recognise this may have an impact on improving the offensive odours at the home. It is evident the staff have a wide range of skills and abilities and many have long term experience of working in the care sector. The staff said they were well supported but it is acknowledged that communication at the home needs to be improved. The recruitment, selection and vetting arrangements at the home need to improve given that the records required by regulation were not complete. The evidence also indicated that staff had commenced employment before the appropriate checks had been made with the Criminal Records Bureau. The providers stated this was not the case and unfortunately the records had not been available for inspection. The staff is also suitably trained and the manager continues to establish an annual training programme for the staff group. Each staff member will also have a individual training plan to make sure their knowledge an skills are up to date and developed. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38. The home is well run by the manager for the best interests of residents. Records continue to improve but some records are incomplete or require further development. This will make sure that clear and comprehensive information is available. The risk assessments and risk management arrangements have significantly improved but further development is required to make sure that every reasonable step is taken to minimise risk. EVIDENCE: The registered manager has been in post since September 2005 and made a positive impact on the way the home is run. The manager clearly has a positive agenda for change in order that the services and facilities can be further developed. The manager also said they were well supported by the registered providers.
Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 22 The manager is undertaking a quality assurance process in order to guide inform and direct the change agenda. The review will take account of the views of residents, their relatives or representatives and professionals that have contact with the home. At the end of the process the manager plans to produce a report of their findings and any action that is planned. The report will then be available to interested parties. The records at the home also continue to improve but certain records need further improvement to meet the standard required. The providers have also improved the risk assessment and risk management arrangements. This has significantly reduced the number of reported accidents and incidents that have occurred. Where a situation arises that potentially compromises a resident’s health, safety or well-being a risk assessment is completed. This identifies any additional action or support the staff is required to take to minimise the assessed risk. In certain instances the guidance direction and information provided to staff about the risk management arrangements needs to be more detailed or written in a clearer manner. Sheldon House DS0000008894.V276749.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 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 24 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 OP3 Regulation 14(1) (a-d) 15(1) Requirement A comprehensive and detailed assessment must be completed for all prospective service users. Timescale for action 30/06/06 2. OP7 Comprehensive and detailed care 30/08/06 plans to meet the needs and preferences of service users must be provided. The environment must meet the minimum standards required. Sufficient communal space must be provided. The home must be clean, hygienic and free from offensive odours. 30/03/07 30/03/07 30/06/06 3. 4. 5. OP19 OP20 OP26 23(2)(b)( d) 13(4)23(2 )(g)(h) 13(3)16(2 )(k) 16(2)(j) 18(1)(a) 6. OP27 7. OP29 19(1)(a) (10) 18(1)(a) 19(10) 8. OP29 Domestic staff must be 30/05/06 employed in sufficient number and at key times to make sure a clean and hygienic environment is provided. The records required by 30/05/06 regulation must be in place before a new member of staff commences employment. A Criminal Records Bureau 30/05/06 application and POVA check must be in place before a new staff
DS0000008894.V276749.R01.S.doc Version 5.1 Page 25 Sheldon House 9. OP37 17 member commences employment. Records required by regulation must be maintained to the standard required. 30/07/06 10. OP38 13(4)(a-c) Satisfactory risk management and risk assessment arrangements must be put in place. 30/06/06 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. Refer to Standard OP7 OP12 Good Practice Recommendations The records of the care plans reviews should be recorded in a consistent place and manner to promote easy access. The recreational and social opportunities should continue to be broadened and increased. Sheldon House DS0000008894.V276749.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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