CARE HOMES FOR OLDER PEOPLE
Sherwell St Ives Road Carbis Bay St Ives Cornwall TR26 2SF Lead Inspector
Paul Freeman Key Unannounced Inspection 12th September 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 Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Sherwell Address St Ives Road Carbis Bay St Ives Cornwall TR26 2SF 01736 796142 01736 798621 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) Mr Ronald James Cottam Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd March 2006 Brief Description of the Service: Sherwell is situated on the main Road to St Ives and has panoramic sea views to the front of the property. The present registered person is in day to day control of the care home has been in charge since 1984. The Home accommodates nine older people and the provider and staff aim to offer a small family unit that is based upon promoting independence and service user lead care. Since April 2001 an extensive refurbishment programme has occurred and phase 1 is now completed. The registered person is now considering extending the property and refurbishing some of the facilities. A small car park is located at the front of the property and there is a lawned area also at the front of the property. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspectors undertook a planned unannounced key inspection on 12 September 2006. The purpose of the inspection was to consider the work that had been undertaken on the requirements set at the last inspection on 3 March 2006 and to inspect other core standards. Therefore some of the key standards considered included assessment of resident’s needs, care planning, staffing arrangements and safe working practises. The registered provider, residents and staff were consulted about the services and facilities provided. The environment, records and documents were also considered. The provider has made good progress on the requirements and recommendations that were set at the last inspection. There are many positive aspects of the services and facilities provided but further measures need to be in place to make sure that residents and staffs health and well being are not compromised. What the service does well:
Prospective residents are assessed to make sure the provider is able to meet their needs. The prospective resident is able to fully participate in the assessment and their relatives or representatives are also consulted. The opinions of any professionals involved with the person are also taken into account. Residents that had recently moved to the home confirmed they were involved in the assessment process and were positively welcomed when they moved to the home. The residents also stated the staff had been supportive during their move and had helped them to settle in their new setting. Health needs are well met and medical services are promptly accessed when required. Residents said they had confidence in the manner their health needs are met and medical practitioners regularly visit the care home. Medicines are also stored and managed safely. Residents are able to administer their own prescribed medication when it is safe and staff assisting residents have been adequately trained. Residents are satisfied with their lifestyles at the home and said they felt in control of their lives. The residents are also satisfied with the recreational opportunities and many choose to make their own arrangements on a day-byday basis.
Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 6 There are no barriers to residents maintaining links with relatives, friends or representatives at the home or in the community. Residents are also satisfied with the meals provided and said a varied menu is in place that reflects their preferences and choices. The residents described the food as “very good” and “fine” and one said, “ I don’t get hungry.” The kitchen has recently been refurbished to a good standard and it is evident that appropriate health and safety practices are in place. The kitchen was also found to be clean and hygienic. Positive arrangements are in place for residents to raise any concerns or complaints they have about the services and facilities provided. Residents said there are no barriers to raising any issues and had confidence any concerns would be dealt with promptly. The home is well maintained and decorated and provides a comfortable and homely setting for residents. Residents said they were very satisfied with the facilities provided. Communal areas are located on the ground floor and comprise of a sitting room at the front of the building and a dining room at the rear. The dining room has been refurbished to a good standard as part of the work undertaken on the kitchen. Many of the bedrooms have been personalised by the occupants and a number also offer en-suite facilities. The home was found to be clean and hygienic and residents said that good standards were maintained at all times. A communal bathroom and toilet are also located on the ground floor, which meets the required standards. Sufficient staff are on duty each day and night to make sure that residents needs can be met and that residents are protected. The staff group are relatively stable and residents clearly have confidence in the manner they undertake their duties. Positive and trusting relationships have been established and the staff has a good understanding of the residents needs, preferences and choices. The staff are well supported and advice, guidance and assistance is available when required. The provider has also recently established annual appraisals for staff to make sure their skills ands knowledge are up to date and to identify any training that is required. Three of the staff have also recently commenced NVQ training. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
Where residents have more complex needs more detailed assessments and care plans are required. This will make sure that a good picture of needs is in place and staff is provided with detailed guidance and direction about the care and support required. The care pan review arrangements also require improvement in order that the provider can make sure the care and support provided reflects the residents’ needs, preferences and choices. The bathroom on the first floor is out of commission and requires improvement. This has been out of use for some time but the numbers of residents at the home have not exceeded eight. Consequently the available facilities meet the minimum standards required. If the number of residents exceeds eight this bathroom would need to be in good working order. The laundry is located on the ground floor and is also in need of redecoration and improvement. The provider stated he is currently in the final stages of arranging for the required work to be undertaken on the first floor bathroom and laundry.
Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 8 The recruitment selection and vetting arrangements were not considered on this occasion given the records were not available at the care home. The requirements regarding recruitment that were set at the last inspection are therefore renotified to make sure that robust arrangements are in place that protect residents. 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. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 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 Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Satisfactory assessments are in place that detail residents needs and satisfy the provider and prospective resident that the home is a suitable setting to meet their individual needs. EVIDENCE: Prospective residents are assessed to make sure the provider is able to meet their needs. The assessment details the person’s needs and includes their preferences and choices about the care and support required. Relatives or representatives are also invited to contribute to the assessment and the opinions of any professionals involved with the person are taken into account. The quality of the assessments has significantly improved and provides a clear summary of the individual’s needs and the care and support required. Relatives and professionals also positively contributed to assessments and a consistent standard has been maintained for residents that have moved to the care home in recent months.
Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 11 One resident was identified as experiencing more complex needs and the provider would have benefited from a more detailed assessment in order that comprehensive guidance and direction was provided to staff about the care and support required. The residents said the staff provide good support and were very welcoming when they moved to the home. The residents were also positive about the manner in which staff had helped them settle into their new environment. A dedicated rehabilitation or intermediate care service is not provided but staff support residents to maintain their independence as far as possible. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 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, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Care plans provide satisfactory information to guide, direct and inform staff about the care and support required. More detailed information would benefit residents that have more complex needs in order that staff is provided with clear guidance and direction. The care plans also need to address social and night-time needs to make sure staff have a full picture of the arrangements required. The arrangements to meet health needs are good and medical services are accessed promptly when required. Medicines are also administered safely by trained staff which promoted the residents health and well being. EVIDENCE: The care planning arrangements have significantly improved since the last inspection. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 13 Each resident has a care plan that details their needs and provides staff with information about the care and support required. Where a resident is able to direct their own care the care plan summarises their needs but there continues to be certain instances where more detailed information and guidance is required. This is particularly clear where residents have more complex needs or require assistance in a specific manner. The care plans do not currently record any information about the night time arrangements required or sufficiently detail residents’ social and emotional needs. There is some evidence that care plans are reviewed but reviews do not appear to occur on a regular basis for all residents. It is also recommended that care plans, reviews and other documents relating to each individual resident are signed and dated. Residents are confident about the care and support they receive and said they were treated with dignity and respect, felt in control of events and were able to direct the care and support provided. Residents also had confidence in the manner their health needs are met and were confident that medical assistance is promptly accessed when required. Medical practitioners regularly visit the care home and during the inspection a District Nurse undertook a routine visit to a resident. Medicines are also stored safely and staff-administering medication has been adequately trained. Residents are able to administer their own prescribed medicines when it is safe to do so. Where staff assist a resident suitable records are maintained and appropriate arrangements are in place to dispose of any medication that is no longer required. It is recommended that where a medicine has been changed or discontinued by a medical practitioner, a clear record is made on the MAR sheet and detailing the directions which is signed and dated. Positive links have been established with a local pharmacist who audits the arrangements in place on a regular basis. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 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, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents feel in control of their lives and are able to decide upon their patterns of daily living. A varied and traditional menu is provided that reflects residents’ choices and preferences and promotes good health. The recently refurbished kitchen is a valuable addition to the home and provides the staff with good facilities to prepare and cook meals. EVIDENCE: Residents said that generally the lifestyle they experience meets with their expectations and the patterns of daily living they wish to follow. Most residents were satisfied with the recreational and leisure opportunities available and provided by the staff. A lot of the residents also prefer to arrange their own day and do not wish to participate in organised activities. There are no barriers to residents maintaining contact with relatives or representatives at the home or in the community. Residents said that visitors were always welcomed and they are able to decide where they meet with their visitors.
Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 15 Residents were also positive about the food and residents said of the meals “ I don’t get hungry”, “very good” and “fine”. The kitchen facilities are of a good standard and have been recently refurbished. Appropriate healthy and safety measures are in place in the kitchen and the provider stated that the equipment is regularly maintained and serviced. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Positive arrangements are in place to protect residents form abuse and there are no barriers to residents or their relatives or representatives raising any concerns or complaints. EVIDENCE: The provider or the Commission has received no complaints since the last inspection. A suitable policy and procedure is in place to deal with any concerns or complaints. Residents also said there are no barriers to raising any issues with the provider or staff and were confident that any concerns would be dealt with satisfactorily. The arrangements to protect residents from abuse have improved and a satisfactory policy and procedure is in place that reflects the Department of Health Guidelines No Secrets. Suitable Whistle Blowing arrangements are also in place and this provides the opportunity for staff to report any concerns regarding abuse to a third party. This offers residents further protection. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 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, 21 and 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The environmental standards at the home are high and residents are provided with a comfortable and homely setting. In contrast the standards of the laundry and first floor bathroom are poor and in need of attention. Once the outstanding work has been completed the outcome for this area would become excellent. The environment is also clean and hygienic which safeguards residents health and well-being. EVIDENCE: The environment is maintained to a good standard and a rolling programme of redecoration is in place. The residents said they were satisfied with the facilities and commented the setting was homely and comfortable.
Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 18 Communal areas are located on the ground floor and comprise of a sitting room at the front of the building and a dining room at the rear. The dining room has also been refurbished as part of the work completed on the kitchen. In recent weeks repairs have been undertaken to the drainage system immediately outside the laundry facilities. This has resulted in damage to the laundry rooms ceiling and windows. The facility therefore requires improvement and the providers stated they are planning to completely refurbish the laundry in the near future. Each of the bedrooms is provided with en-suite facilities and a communal toilet and bathroom is located on the ground floor. The bathroom located on the first floor is currently out of commission and requires refurbishment. The provider has agreed that occupancy will not exceed eight residents while this bathroom is not in operation. The provider also stated they are also planning to refurbish the facility in the near future. The home is clean and hygienic and residents said that good standards are maintained at all times. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 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 and 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The judgement reflects the outstanding requirement regarding recruitment that was not inspected given the records were not valuable. If compliance has been achieved the outcome in this area is good. Sufficient numbers of staff are on duty each day and night to provide the care and support required by residents. The recruitment arrangements must be robust to make sure residents are not placed at risk. Staff are provided with training opportunities to develop their knowledge and skills so that good standards of care can be maintained. EVIDENCE: The staff group at the home are relatively stable and it is evident that positive and trusting relationships have developed between staff and residents. It is also clear that staff have a good understanding of the residents’ needs, preferences and choices. Residents described the staff as “very nice”, responsive, sensitive and flexible in the manner they work. Residents that have recently moved to the home were also positive about the ways in which the staff helped them to settle in their new environment.
Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 20 The staff was also positive about working at the care home and said they were well supported. The recruitment selection and vetting arrangements were not considered on this occasion given the records are not held at the care home. The requirement set at the last inspection is therefore renotified to make sure that robust arrangements are in place that protects residents. The training arrangements for new staff have been improved and this has resulted in staff participating in core skills training to make sure their knowledge and skills are up to date. In addition two staff are commencing NVQ 2 training and another member of staff has commenced the NVQ 3 qualification. The provider has also established a system for undertaking annual staff appraisals that are due to commence in the near future. The annual appraisal arrangements will also assist the provider to identify any outstanding training needs. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 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, 35 and 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is managed appropriately and in a manner that promotes the best interests of residents. The quality assurance arrangements are improving but continue to rely on informal channels of communication. More formal arrangements are in the early stages of development. Improved arrangements will ensure that the provider has a clear picture of the positive elements of the services and facilities provided and the opportunities for improvement. Measures are in place to promote safe working practises but the risk assessment and risk management arrangements require further improvement. This will make sure that residents are safeguarded. Suitable arrangements are also in place regarding fire detection and prevention but staff training in this area is poor. This requires urgent attention so that every reasonable step is taken to protect residents.
Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home is run on a day to day basis by the registered provider who has recruited an experienced senior carer to assist in the coordination of the care and support provided. At this time the provider does not hold the Registered Managers Award. Residents are positive about the manner the services and facilities are run and there are no barriers to residents raising any concerns if required. The quality assurance measures have improvement but further improvement is required to meet the appropriate standard. The provider regularly consults with residents on an ongoing basis to make sure they are satisfied with the services and facilities. However there are no records of the consultations or any apparent mechanisms to use the information in an annual report as required by regulation. Additional arrangements to consult with residents are in the process of develop. This includes a questionnaire for residents, relatives and representatives but the current draft only considers the accommodation and meals. It is recommended this format is broadened to include other key aspects of the services provided. The provider stated the care home does not offer any support or assistance about the management of residents’ personal finances. Where assistance is required an external third party is identified. A range of policies and procedure are in place that promotes safe working practises. The equipment and services at the home are regularly serviced and maintained and satisfactory arrangements are in place regarding fire prevention and detection. The frequency that staff undertake fire drills or fire training is poor and this requires urgent attention to make sure that residents are safeguarded. The Environmental Health Officer has recently inspected the facilities and has no concerns about the standards maintained. Following the last inspections the provider and staff have become more mindful about managing unreasonable risks that are encountered around the home. The rate of accidents and incidents is very low but the evidence that risk
Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 23 assessments have been undertaken is limited. The senior carer said they were in the process of established a suitable format for recording risk assessments and risk management plans and this will help to make sure that robust arrangements are in place that safeguard residents. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 1 X X X X 1 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14, 15 Requirement Detailed Service User Plans must be introduced for all service users. Care plans must be reviewed each month and a suitable record must be made. (Previous timescale of 30.3.05 not met) The bathroom on the first floor must meet the required standards and be available for use by service users. If occupancy exceeds eight service users the bathroom on the first floor must be available for use. Suitable laundry facilities must be provided that promote safe working practises and ensures the facilities are maintained and decorated to a good standard. Timescale for action 30/12/06 2. OP7 15 30/11/06 3. OP21 23(2)(j) 30/03/07 4. OP21 23(2)(j) 30/09/06 5. OP26 13(4) 16(2)(e) 23(2)d 30/12/06 6. OP29 18 19 and sch 2 The recruitment and selection 30/12/06 arrangements must be developed to be more robust and
DS0000009163.V309891.R01.S.doc Version 5.2 Page 26 Sherwell meet the requirements stated in schedule 2. (Previous timescale of 30.7.05 not met) 7. OP29 19 and schedule 2 24(1) New staff members must not commence care duties until the registered person has received a satisfactory POVA check Formal quality assurance processes that are verifiable must be introduced. The conclusion of the review must be recorded and made available to interested parties. Risk assessments must be undertaken and recorded when any situation arises that could compromise a service users health, safety or well-being. (Previous timescale of 28.2.05 not met) 30/10/06 8. OP33 30/12/06 9. OP38 12, 13 30/11/06 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 OP9 Good Practice Recommendations More detailed assessment and care planning information should be in place for service users who experience more complex needs. Where a medical practitioner changes or stops a prescribed medication a clear record that is signed and dated should be made on the MAR sheet. Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 27 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
© 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 Sherwell DS0000009163.V309891.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
