CARE HOMES FOR OLDER PEOPLE
Sherwell St Ives Road Carbis Bay St Ives Cornwall TR26 2SF Lead Inspector
Paul Freeman Unannounced Inspection 3rd March 2006 09:30 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.V282078.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. Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 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.V282078.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd February 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 who 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 the garden area is continues to be improved. Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two Inspectors undertook a planned unannounced inspection on 3 March 2006. The purpose of the inspection was to consider the work that had been undertaken on the requirements set at the last inspection on 25 April 2005 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. Other inspection visits had occurred on 21 July 2005 and 11 August 2005 to offer advise and guidance about the standards required in respect of the assessments of residents needs and risk assessment and management arrangements. Outstanding requirements and recommendations from previous inspections have been renotified in this report. It is noted that five requirements have been renotified to the provider on at least two previous occasions and one requirement is renotified in this report for the second occasion. Failure to comply with the Care Home Regulations 2001 can result in the Commission considering further action. The provider, staff and residents fully cooperated and were very helpful throughout the inspection period. What the service does well:
Residents are satisfied with their lifestyles at the home and said they felt in control of their lives. The majority of residents are also satisfied with the recreational opportunities and choose to make their own arrangements on a day-by-day basis. 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 they were given “a good range of choices”. Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 6 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 plaice 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 also recently 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 ensuite facilities. The home was found to be clean and hygienic and residents said that good standards were maintained at all times. A communal bathrooms and toilet are also located on the ground floor that meet the required standards. Sufficient numbers of staff are on duty each day and waking night staff work each night. The numbers of staff on duty are determined by the needs of the residents and the number of residents at the home. Additional staff is also employed if required. Residents said they found the staff to be reliable, flexible and responsive to their needs and requests. It is evident that positive relationships have been established between the residents and staff. What has improved since the last inspection?
The assessment of prospective residents needs arrangements have been significantly improved following the last inspection visit. Each prospective resident is assessed by the provider to make sure they are satisfied the individuals needs can be met by the services and facilities provided. The prospective residents are invited to participate in the assessment process and their relatives are also consulted. In addition the views of any professionals that are in contact with the prospective resident are taken into account.
Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 7 Resident 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. The improved assessment arrangements also mean that residents are confidant their needs will be met before they enter the home. The recruitment arrangements for new staff have been improved in recent months but continue not to meet the required standard. This is because the records about recruitment that are required by regulation are not all in place. The shortfalls in the current arrangements could potentially place residents at risk. Staff training opportunities has also improved and a training programme is being established. This will mean that staff is able to update and develop their knowledge and skills. In addition staff are able to undertake NVQ 2 training if they wish. Positive arrangements are in place for staff to access informal support, advice and guidance when required. More formal arrangements continue to be introduced so that staff is well supported in the work they undertake. Records at the home continue to improve but in certain areas the practises are not satisfactory and do comply with the regulations. What they could do better:
The care planning arrangements are not adequate and each resident must have a care plan that details the care and support they require. This will assist the staff to meet the residents’ needs in the manner that reflects their choices and preferences. Reliable arrangements also need to be established to regularly review the care plans to make sure the service provided is up to date and comprehensive. Resident should be supported and helped to broaden and extend their leisure opportunities where this is required. No policy and procedure was available at the home about the protection of residents against abuse. This is not acceptable and a policy must be readily available for staff to consult if required. The current situation could therefore potentially place residents at risk. The provider said the policy had been removed to revise the contents to make sure they meet with the required standard. The provider also stated that any concerns or allegations are treated seriously and referred to the statutory authorities for investigation.
Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 8 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 resided at the home have not exceeded eight. Consequently the available facilities meet the minimum standards. 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 considering extending the property further and the refurbishment of the first floor bathroom and the laundry would be part of the plan. There are no verifiable arrangements in place to formally assess and consider the quality of the services provided. An annual quality assurance process must take place for the provider has a clear understanding of residents’ views and any actions that are required to improved the service and setting. The safe working practises and risk assessment and risk management arrangements require improvement to make sure robust arrangements are in place that promote the health, safety and welfare of residents and staff. 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.V282078.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 Sherwell DS0000009163.V282078.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 4. Satisfactory assessments are in place that detail residents needs and satisfy the provider and prospective resident the home is a suitable setting to meet the individual’s needs. EVIDENCE: The requirements to improve the assessment arrangements of residents were reviewed and the records of residents that have recently moved to the care home were considered. The assessment arrangements were found to be satisfactory and the provider had undertaken assessments of needs that detailed the resident’s needs and choices. The information also enabled the provider to be satisfied the home could meet the individual’s needs and requirements. The information in the assessments is also satisfactory for the provider to be able to develop appropriate care plans so that the staff is clear about the care and support required.
Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 11 It was evident that residents have been able to participate in the assessment process and their relatives had also been consulted. The views of speaclist workers that were involved with the residents at the time of their move to the home are also taken into account. Residents that had recently been admitted said they were able to contribute to the assessment process and were pleased their relatives had been involved. 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. The assessment arrangements had also given the prospective residents confidence their needs would be met when they entered the home. Sherwell DS0000009163.V282078.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 and 11. The documentation supporting the caring activity is inadequate. Care plans need to be more detailed and provide good information about the care and support required. This will further improve the service and support provided to residents. EVIDENCE: The provider has only made limited progress on improving the care plans. This is because they have focused upon establishing reliable assessment arrangements. Care plans do not appear to be in place for all residents and where a care plan has been established they are very general and do provide a clear picture of the residents needs, preferences and choices. The review arrangements were spasmodic. In certain instances there was no evidence to indicate if any consideration had been given to the effectiveness and appropriateness of the care and support provided. Reviews therefore need to be undertaken each month to make sure the residents needs, choices and preferences are being met.
Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 13 Therefore quality of the records does not accurately reflect the quality of the care provided. The provider stated that daily consideration is given to the arrangements in place and where required the care and support is adjusted accordingly. Residents said they found the staff to be “polite”, “caring” and sensitive to their needs. Opportunities are also provided for residents to share their wishes about the steps they would like to be taken in the event of poor health or death. Many of the residents do not wish to share this information and prefer to discuss their preferences with their relatives or representatives. Sherwell DS0000009163.V282078.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 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. Two residents did comment they would like to consider other recreational options and this included opportunities outside the care home. The residents said they felt in control of their lives found the staff to be flexible about the routines they wished to follow. Residents are also confidant that staff helps them to maintain their independence and are readily available to offer assistance and support where required.
Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 15 Residents therefore felt they were able to direct the care and support they required. Residents were also satisfied with the food provided and some said the meals were “very good” and “fine”. The residents said they were provided with “a good range of choices” and confirmed the menu is varied and reflects resident’s preferences and choices. The kitchen has recently been completely refurbished to a good standard and was found to be clean and hygienic. Appropriate health and safety arrangements are in place and these include monitoring the temperatures of fridges and freezers and appropriate controls of the food stocks at the home. The wall between the kitchen and dining area has been fire proofed and this has improved the fire safety precautions at the home. The provider is confidant the arrangements comply with the Fire Regulations but the Fire Officer has not yet inspected the work. Sherwell DS0000009163.V282078.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. Complaints and concerns are dealt with satisfactorily and there are no apparent barriers to residents raising any issues with the provider or staff. No policy and procedure for protecting residents against abuse was available for consideration or for the staff at the home. This could place residents in a position of unreasonable risk. EVIDENCE: Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 17 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 confidant that any concerns would be dealt with satisfactorily. The policy and procedure that guides and directs the staff about the protection of resident from abuse was not available for consideration. The provider said this was because the document was currently in the process of revision. The policy and procedure previously considered at past inspections did not reflect best practise or the Department of Health Guidelines ‘No Secrets’. It is also of concern that staff do not have any access to a policy. The provider said that any concerns would be reported to the statutory authorities for investigation. Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 18 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. The home is clean, hygienic, well maintained and decorated, and provides residents with a homely and comfortable setting. The first floor bathroom needs to be in service for the convenience of the residents that reside upstairs. The laundry facilities also require improvement to promote safe working practices. 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. 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 recently been refurbished as part of the work completed on the kitchen. Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 19 Bathrooms are located on both floors but the facilities on the first floor are currently out of commission and require refurbishment. The provider has agreed the bathroom will be made available if the occupancy at the home exceeds eight residents. In addition some of the bedrooms are also provided with a sink and toilet. The laundry is located on the ground floor and is in need of redecoration and certain repairs are outstanding. The provider stated he is currently considering extending the property further and the refurbishment of the first floor bathroom and the laundry would be part of the plan. The home was found to be clean and hygienic and residents said that good standards were maintained at all times. Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 20 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, 29 and 30. Sufficient numbers of staff are on duty each day and night to provide the care and support required by residents. The recruitment arrangements are not robust and could result in residents being placed at risk. Staff is provided with training opportunities to develop their knowledge and skills so that good standards of care can be maintained. EVIDENCE: The staff duty rosters indicate that sufficient number of staff is on duty each day and overnight to meet the needs of the residents. The numbers of staff on duty are determined by the needs of residents and the number of people residing at the home. A second duty roster is also in place to plan for increased staffing levels if more residents move to the home. Waking night staff is also on duty and additional staff can be called upon in an emergency. The provider has also put in place on call arrangements when they are not on duty at the home. Residents said they found the staff to be reliable, flexible and responsive to their needs and requests. It is evident that positive relationships have been established between the residents and staff. The recruitment, selection and vetting arrangements for new staff have improved since the last inspection. However certain records required by regulation were not in place and this could place residents at risk.
Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 21 Staff training opportunities has improved and plans are being established for the staff to undertake core skills training to update their knowledge and skills. Plans are also in place for new staff to commence NVQ 2 training. Staff appraisals are being introduced in the near future and this process will also identify staff training needs and further develop the staff-training programme. Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 22 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, 36, 37 and 38. There are no formal arrangement in place to assess the quality of the services and facilities provided so that improvements can be made. The informal support to staff is reliable but more formalised support systems are not in place to make sure that good standards of care and support are provided. The records at the home are improving but need to be further developed so that essential information that supports the services and facilities provided is available. Some of the risk assessment and risk management arrangements are not satisfactory and could place residents at risk. EVIDENCE: The provider stated the care home do not offer any support or assistance about the management of residents personal finances. Where assistance is required this is provide by a third party who is external to the home.
Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 23 The four requirements and one recommendation that were set at the last inspection were also considered. The provider has taken steps for a senior staff member to commence the NVQ 4 in care and management. By completion of the qualification the provider will need to advise the Commission of any planned changes to the management arrangements at the home. Any adjustments to the management arrangements will need to be reflected in the homes statement of purpose and service users guide. The provider said the quality of the services provided was informally considered each day with the residents. Therefore positive informal arrangements are in place to consult with residents. However there are no formal arrangements and an annual quality assurance report is not completed as required by regulation. The Inspectors were told that formal systems would be introduced during 2006 and this will include a report that summarises the finding and details any actions that are planned. Staff said they have access to reliable advice and guidance from Mr Cottam and the senior carer on a day-to-day basis. The arrangements to formally supervise and support staff have begun to be improved and the regular staff meetings that have been introduced can illustrate this. In addition a format is being established to facilitate an annual appraisal of each staff member. It is planned that appraisals will commence in the near future and will lead into regular formal supervision and support. The staff at the home keeps a daily record of events that occur to each residents and there are no barriers to residents accessing the information. Other records are incomplete or not completed to the required standard. These have been addressed earlier in the report. The home has policies and procedures to promote safe working practices but they need to be updated to provide staff will clear guidance and to make sure legal requirements are met Positive arrangements are in place to maintain the equipment and services provided at the care home and the arrangements about fire protection have improved. The current arrangements for wedging open signed fire doors are not satisfactory. The provider stated that fire doors are only wedged during the daytime. The arrangements in place to minimise risks experienced by individual residents continue to be improved but are also not satisfactory. There is limited documentary evidence that risks are taken proper account of and consequently the guidance to staff is insufficient. Staff indicated that in most
Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 24 situations they rely on verbal communication to share the risk management arrangements required. This is not acceptable and could result in residents and staff being placed at risk. The provider is required to make sure that any events that could potentially compromise a resident’s or staff’s health, safety or welfare is risk assessed and a suitable record of the conclusion is made. Any action required to minimise the assessed risks will then need to be part of the individuals care plan. It was noted that no accidents or incidents have been reported following the last inspection. The requirement to provide satisfactory records regarding accidents and incidents is renotified. Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 25 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 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 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 1 3 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 2 Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 26 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. (Previous timescale of 28.2.05 not met) Care plans must be reviewed each month and a suitable record must be made. (Previous timescale of 30.3.05 not met) Policies, procedures and guidelines regarding adult protection must established and reflect the Department of Health’s guidance No Secrets. (Previous timescale of 30.1.05 not met) A suitable adult protection policy that reflects the Department of Health’s guidance must be available for staff to consult at any time. 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
DS0000009163.V282078.R01.S.doc Timescale for action 30/07/06 2. OP7 15 30/05/06 3. OP18 12 17 and schedule4 30/05/06 4. OP18 13(6) 30/04/06 5. OP21 23 30/12/06 6. OP21 23 30/09/06 Sherwell Version 5.1 Page 27 7. OP26 8. OP29 9. OP29 10. OP33 11. 12. 13. OP36 OP37 OP38 14. OP38 15. OP38 16.
Sherwell OP38 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. 18 19and The recruitment and selection schedule2 arrangements must be developed to be more robust and meet the requirements stated in schedule 2. (Previous timescale of 30.7.05 not met) 19 and New staff members must not schedule 2 commence care duties until the registered person has received a satisfactory POVA check 24 Formal quality assurance processes that are verifiable must be introduced. The conclusion of the review must be recorded and made available to interested parties. 18 Formal supervision of staff with appropriate records of each session must be established. 17 The records required by regulation must be in place. 13, 23 The registered person must make arrangements to ensure that nominated fire doors are not wedged open at any time. (Previous timescale of 30.1.05 not met) 12, 13 The accident book must be and 17 completed in a manner that details the circumstances of the accident, the action taken and the outcome of the action. 12, 13 All Health and Safety policies and 23 and procedures must be reviewed, updated and adjusted accordingly. Where appropriate professional advice must be sought. (Previous timescale of 30.3.05 not met) 12, 13 Risk assessments must be 13(4)c 16(2)e 23(2)d
DS0000009163.V282078.R01.S.doc 30/12/06 30/05/06 30/04/06 30/12/06 30/07/06 30/07/06 30/05/06 30/08/06 30/05/06 30/05/06
Page 28 Version 5.1 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) 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. 1. Refer to Standard OP12 OP31 Good Practice Recommendations Services users should be supported when they want to broaden their recreational opportunities. The registered person should inform the Commission of any plans to change or develop the management arrangements at the home. Sherwell DS0000009163.V282078.R01.S.doc Version 5.1 Page 29 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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