Inspection on 16/01/06 for Shelley Park & Shelley House

This inspection was carried out on 16th January 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shelley Park & Shelley House 27/12/08

Shelley Park & Shelley House 19/09/06

Shelley Park & Shelley House 28/06/05

Shelley Park & Shelley House 13/01/05

Shelley Park & Shelley House 07/07/04

Shelley Park & Shelley House 29/03/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 Shelley Park & Shelley House 32 Florence Road Boscombe Bournemouth Dorset BH5 1HQ Lead Inspector Joanne Pasker Unannounced Inspection 16th January 2006 09:30 Shelley Park & Shelley House DS0000020492.V277905.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 Shelley Park & Shelley House DS0000020492.V277905.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. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shelley Park & Shelley House Address 32 Florence Road Boscombe Bournemouth Dorset BH5 1HQ 01202 396933 01202 396933 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) Shelley Park Limited Mrs S Poultney Care Home 37 Category(ies) of Past or present alcohol dependence (1), Physical registration, with number disability (36), Physical disability over 65 years of places of age (36) Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named service user (as known to the CSCI) to be accommodated in the category YA (A). This service user requires personal care. The above service user’s care plan is to be reviewed monthly by the multi-disciplinary team, to include the placing Social Worker during the first six months of admission, to ensure the user’s needs are being met by this placement. (No review dates were set on Shelley Park & Shelley House Care Assessment/Plans). Staff must receive professional training in the management of the user’s Cognitive and emotional functioning abilities, behaviours and needs. The age range of service users permitted to be admitted to this establishment is 18 years and above. Service users with acquired brain injury may be cared for at this establishment if it is evident that the staff employed have the skills, knowledge and competencies to care for them and that their qualifications and training in this field of practice are current. i.e. Within the previous three years. 28th June 2005 3. 4. 5. Date of last inspection Brief Description of the Service: The home provides care for up to thirty-six younger adults who have some form of neurological dysfunction. It is situated in a residential area of Boscombe close to the shopping centre and within easy walking and wheelchair distance of the promenade and beaches. There are good transport links both locally and nationally, with several bus stops and coach and train stations situated nearby. Shelley Park and Shelley House are two buildings located in the same grounds and owned by Shelley Park Ltd. A pleasant garden with garden furniture separates the two buildings. There is off street parking at the front of the building for visitors or parking is available on the main road and side streets, directly outside the home. Shelley Park is the main residential unit and Shelley House ground floor is used for daily living activities and therapy sessions. There is a small snoezelen (multi-sensory) room and adapted kitchen area. This building also provides office accommodation on the first floor for the owners and the administrator. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 5 Shelley Park provides accommodation over four floors and a lift is available to floors 1 - 3. The home has 21 single bedrooms 1 of which has an en-suite facility and 5 double bedrooms. Shelley Park provides care for young adults both male and female with neuro disability resulting from a wide range of conditions including severe brain injury or disease, multiple sclerosis, cerebral palsy, stroke and spinal injury. The home has its own transport and regularly organises social outings. Mrs Sally Poultney - one of the Directors - is also the Registered Manager and there is a general manager, Simone Garland, who oversees the day-to-day running of the home. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second of two statutory inspections required in accordance with the Care Standards Act 2000. The lead inspector was Jo Pasker who was accompanied by regulation manager, Sue Barber. The inspection took place on 16 January 2006 and started at 09.30 hrs and was completed by 14.00 hrs. The total inspection time, including preparation, travelling, inspection and report writing was 16 hours. The inspection team spoke to 6 residents, 3 staff and gathered information from the manager and all documentation requested was made readily available. During the course of the day the inspection team also observed staff interaction with residents, the carrying out of routine tasks and conducted a tour of the premises. Additional information used to inform the inspection process included comment cards and formal notifications of events regularly provided to the Commission by the registered provider. There has been 1 complaint made to the home since the last inspection, which was investigated by the Environmental Health office and partially upheld. The inspector is grateful for the time and contributions made throughout the day by service users, staff and management. This report should be read in conjunction with the last report dated 28 June 2005. What the service does well: What has improved since the last inspection? Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 7 The home’s Death and Dying policy has been updated to include the need to contact the Commission for Social Care and Inspection in the event of the death of a service user, submit a Regulation 37 form and keep any medication at the home for a further 7 days (in the circumstances of a Coroner’s inquest). The home is now providing Regulation 37 forms to the Commission in the event of any notifiable accident or incident that occurs. The bathroom tiles have been replaced in one of the shower rooms, making it more comfortable and hygienic. All of these improvements follow a requirement and recommendations made following the last inspection. What they could do better: As a result of this inspection a total of 7 requirements and 1 recommendation have been made. All information relating to any resident must be securely stored and documented and not left in communal areas where it can be seen by others, leading to a breach of confidentiality. Although the home was generally well maintained, several areas where seen to need some minor repair or maintenance to ensure it remains a pleasant and safe environment to live in. These included repairs to bedroom furniture, radiator covers and emergency lighting. Some shared bedrooms do not suit resident’s needs and lifestyles and occupancy and layout in these rooms needs review by the home to ensure they meet relevant the Commission’s minimum standards, fire service and Health and Safety executive requirements. All dirty laundry trolleys need to be appropriately stored, preferably in sluices until ready for laundering and all sluice doors must be kept closed, to maintain hygiene and infection control measures. The recruitment process must be fully followed so that residents can be assured suitable staff are providing their care. The home must obtain 2 suitable references for any newly employed staff, prior to them commencing work. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 8 The home are required to provide evidence that they have been assessed by the local fire service and Health and Safety executive, with regards to meeting relevant requirements made about the layout and health and safety of the home. Currently some nursing stations are placed in unsuitable locations, some rooms may not meet residents’ needs, there is a steep floor ramp, which may be a possible hazard, and oxygen cylinders are stored in corridors. 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. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 9 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 Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 10 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): Standards 2 and 5 were assessed at the last inspection and met. EVIDENCE: Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 11 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): Standard 10 Standards 6, 7 & 9 were assessed at the last inspection and met. Residents cannot be sure that personal information is handled appropriately and that their confidentiality is maintained by the home. EVIDENCE: During a tour of the premises it was observed that some nursing stations were inappropriately positioned in communal areas, with 1 in an open corridor and the other surrounded by entrances to a sluice and shower room. At both stations there was evidence of residents personal care details, with confidential information either lying on the desk unattended or written on a board within others view. The home must ensure that all records are securely stored to prevent any further breaches of confidentiality and give serious consideration to the position of their nursing stations. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 12 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): Standard 15 Standards 12, 13, 14, 16 & 17 were assessed at the last inspection and met. Residents are encouraged to maintain contact with the local community and their relatives and friends are welcomed into the home. EVIDENCE: Visitors are welcome at any time and residents can go out of the home with family and friends for outings. Some residents’ relatives take them out regularly and others attend local day centres and community groups in the area. Staff confirmed that any residents, who chose to develop intimate relationships with another person, were given the appropriate support and guidance and their privacy maintained. Shelley Park & Shelley House DS0000020492.V277905.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): Standards 19 & 21 Standards 18, 19, 20 & 21 were assessed at the last inspection. The home now follows all formal procedures to ensure that service users physical and emotional health needs are fully met. The home has implemented a previous recommendation to update the death and dying policy, now ensuring that all service users rights are respected when ill or dying. EVIDENCE: Following a requirement made from the last inspection, the home is now submitting Regulation 37 reports to the Commission. This ensures that all information regarding any accident, incident, illness or injury is shared with the Commission within a 24 hour time period. The home’s policy and procedure on death and dying has now been updated following a previous recommendation. It now ensures that that the Commission is contacted in the event of resident’s death and that all medication will be retained for a period of 7 days afterwards, in case there is a coroner’s inquest. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 14 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): Standards 22 & 23 The home has a robust complaints system, which ensures that complaints are managed properly and residents and relatives can be sure that their concerns will be listened to and acted upon. Adult protection is appropriately well addressed in staff training, policies and practice in order to safeguard residents from potential abuse and harm. EVIDENCE: The Commission has received no complaints since the last inspection, although the home itself has received 1 complaint, which was investigated by the Environmental Health department. This complaint was found partially upheld. The complaints file was viewed on the day of inspection and there was evidence of all concerns raised with the home, being well documented and any details, action and outcome clearly stated. Service users are given a copy of the complaints procedure in their welcome pack upon arrival at the home and this is then further explained to residents and families by staff. The home has good policies and procedures in place for the protection of residents from abuse or neglect and a mandatory training day is held every month to ensure all staff receive training in adult protection procedures. Individual behavioural care plans have been drawn up with appropriate professional input for any residents who exhibit physical or verbal aggression. This ensures that staff understand and appropriately manage this behaviour, whilst maintaining the safety of the resident, themselves and others. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 15 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): Standards 24, 25, 27 & 30 Standards 24, 27 & 30 were assessed at the last inspection The home is comfortable and homely and clearly reflects the lives of the people who live there, although some maintenance work is needed to ensure a safe environment is maintained. Some shared bedrooms do not suit resident’s needs and lifestyles and occupancy in these rooms should be reviewed by the home. All bathing and shower facilities now fully meet residents needs and requirements. The home is generally clean and free from any offensive odours, although dirty laundry trolleys being stored in communal areas, do compromise hygiene. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 16 EVIDENCE: It was evident from a tour of the premises that the home provides a comfortable, homely environment for residents to live in. There is on going work to provide more office space and improve fire access and refurbishment of the buildings is also on going. However, the home was still awaiting the local fire service to return and re evaluate recent work carried out, with regards to its fire safety. Also several maintenance concerns were seen during the tour of the premises, including emergency lighting not being properly fitted to the ceilings, bedroom furniture needing repair or making safe and radiators without protective covers. There were 2 double rooms seen which did not appear large enough to meet the requirements of residents in wheelchairs and 1 which needs review by the fire service, as a bed was blocking a fire door. The home needs to review occupancy in these rooms and ensure that the usable floor space provided meets the appropriate National Minimum Standards and local fire service and environmental health requirements. The ground floor shower room has had its tiles replaced, following a previous requirement made and is now appropriate for residents use. Although the home was seen to be generally clean and free from offensive odours, some areas were not considered hygienic, with dirty laundry trolleys being kept in communal corridors and hallways. These should be appropriately stored in sluices until moved to the laundry for washing, to ensure infection control measures are maintained. Sluice doors were also seen to be propped open yet these should remain closed to again maintain acceptable hygiene and health and safety standards. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 17 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): Standard 32 & 34 Standards 35 & 36 were assessed at the last inspection and met. Service users benefit from a dedicated staff team who receive good training in understanding different disabilities and are able to fully support and meet residents’ needs. There is a recruitment procedure in place but his has not always been followed by the home, therefore placing service users at risk of possible harm or abuse. EVIDENCE: Staff were observed to be caring and competent in their work during the inspection and interaction between residents and staff was clearly good, with many enjoying a shared sense of humour. Residents spoken to stated that the staff “are ok” and “they do a good job”. Training for staff is good with a mandatory training day held every month to ensure all staff, new and existing, are kept up to date. The general manager comes in at night to enable all night staff to also remain updated. These include: • Effective communication DS0000020492.V277905.R01.S.doc Version 5.1 Page 18 Shelley Park & Shelley House • • • • Challenging behaviour Adult protection Role of the care worker Needs of the service user Specific training based on residents needs is carried out with new staff at induction and any changes in residents needs are addressed in specific training sessions as and when needed. The files of 3 staff members were viewed on the day of inspection but only 1 file was found to contain 2 references as required. All other necessary documentation was present. From discussion with the manager it appeared that for 1 employee, a reference was never returned and for another employee, it was their first job since leaving college. The home was advised that verbal documented and character references would have been appropriate in these circumstances and that all future prospective employees must have 2 references prior to starting work. All 3 staff had received enhanced CRB and POVA first checks prior to commencing work. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 19 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): Standards 39 & 42 Unable to assess Standard 37 as the registered manager was not available at the time of inspection. To be assessed at the next inspection. Standards 42 & 43 were assessed at the last inspection and met. Residents can be confident that their opinions are listened to as effective quality assurance systems are in place, based on the views of themselves and stakeholders. The health, safety and welfare of residents and staff are generally well promoted and protected. However, some areas require further risk assessment by the home to ensure that risks to residents’ safety are kept to a minimum. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 20 EVIDENCE: During 2005 a quality assurance questionnaire was issued to residents, relatives and other stakeholders and the returned cards seen. Information received from these is verbally fed back to residents and comments acted upon. A service user had previously indicated that they were unhappy with the lack of choice provided for vegetarian residents. The home had responded by discussing this with them and now there is a daily choice of vegetarian meals available also. Evidence of internal audits carried out by the home in the last year were also seen. The home has also just completed its annual quality assurance report for 2005 and provided the Commission with a copy of it. It is recommended that this be issued on headed paper, signed by the manager and include details of evidence used to improve future reports. In relation to health and safety, all staff fire training was seen to be up to date and the home’s service certificates seen were in date. Records of accidents/incidents were well kept although they lacked any evidence of what follow up action was taken, if any. The home submits regulation 37 forms to the Commission as required and in a timely manner. However, as previously noted in the environment section of this report, several maintenance and health and safety issues were noticed during a tour of the premises. The nursing work stations (already discussed in the individual needs and choices section of the report) may also represent a health and safety issue given their inappropriate locations. Also, the ramped floor area to level ‘B’ is very steep and may represent a hazard to staff and resident’s safety. Both of these issues must be fully assessed by the Health and Safety executive to ensure that the home maintains acceptable health and safety standards. Other areas were seen to be possible fire hazards and included a fire door in the loft area that was left unlocked and oxygen cylinders chained to the wall on different floors. Advice should be sought from the local fire service regarding appropriate storage of these cylinders. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 21 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 X 2 X 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 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X 1 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X 3 X X 3 X X 2 X Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? NO 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 YA10 Regulation 17(1)(b) Requirement The home must ensure that all documentation/information relating to residents is securely stored to maintain confidentiality. The home must be well maintained and repairs made in a timely fashion. The home must review all double occupancy rooms and ensure that the size and layout are suitable to meet resident’s needs and safety. This should be done in conjunction with the local fire service and health and safety executive and evidence provided. Timescale for action 31/01/06 2 YA24 23(2)(b) 16/07/06 3 YA25 23(2)(f) 16/07/06 4 YA30 13 All dirty laundry trolleys must be 31/01/06 stored in appropriately and sluice doors kept closed. All new staff must only commence employment after 2 satisfactory references have been received by the home. 31/01/06 5 YA34 19 Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 23 6 YA42 23(4) 7 YA42 23(5) Oxygen cylinders should be 16/07/06 stored safely. The home must provide evidence from the local fire service that they have been contacted and assessed any potential fire hazards with regard to this. All nursing station locations and 16/07/06 the ramp to level ‘B’ must meet health and safety requirements. The home is required to provide evidence from the Health and Safety executive, that they have been contacted and assessed these areas with regard to staff, resident and visitor safety. 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 YA39 Good Practice Recommendations It is recommended that future annual quality assurance reports are issued on headed paper, include details of evidence used and be signed by the manager. Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Shelley Park & Shelley House DS0000020492.V277905.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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