Inspection on 26/04/05 for Shire Oak House

This inspection was carried out on 26th April 2005.

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

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

Other inspections for this house

Shire Oak House 06/07/06

Shire Oak House 05/10/05

Shire Oak House 08/01/05

Shire Oak House 01/09/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Shire Oak House 33 Lichfield Road Shire Oak Walsall. WS9 9DH Lead Inspector Maggie Bennett Unannounced 26 April 2005 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 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. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shire Oak House Address 33 Lichfield Road Shire Oak Walsall West Midlands. WS99DH 01543 372331 01543 372331 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Quality Homes (UK) Ltd. Ms Michelle Ward Care Home 26 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (26) of places Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 08/01/2005 Brief Description of the Service: Shire Oak House is a large detached residence in the Shire Oak area of Walsall. It is surrounded by open countryside. The home has been extended and provides accommodation for up to 26 people. All bedrooms are single and the majority have an en suite toilet and wash hand basin. There is a passenger lift to the first floor. The home has parking facilities to the front and extensive gardens to the rear. It is owned by Quality Homes (UK) Limited who have other homes in the Walsall and Wolverhampton area. The home is registered to accommodate residents who are over 65 years of age, up to 5 of whom may have dementia. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out on a weekday between the hours of 8.45 a.m. and 5.55 p.m. During the inspection a tour of the premises was made, 7 residents, 1 relative and 2 members of staff were spoken to and discussion took place with the registered manager. The assessment information and care plans of a random sample of residents were seen. Since the last inspection on 8th January 2005, a registered manager has been appointed to the home. What the service does well: What has improved since the last inspection? There have been a number of improvements since the last inspection and this is reflected in the decrease in number of statutory requirements made. A manager has been appointed and she is already improving the quality of assessments and care planning. The manager has taken steps to ensure that the home only admits those residents whose needs can be satisfactorily met at Shire Oak. Staff morale has undoubtedly improved, although difficulty is still being experienced in recruiting suitable staff. Staffing ratios have improved Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 6 and are now adequate. Staff are making steady progress with the National Vocational Qualification training. Residents (with one exception) said that their bedrooms were now sufficiently warm in the daytime. There has been an improvement in recruitment procedures and the manager is clear of her responsibilities under the Protection of Vulnerable Adults Scheme. Residents felt that there was an improvement in the choice of food available at tea-time, particularly as they were now offered a hot alternative. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6 Prospective residents receive the benefit of an assessment before they are admitted to the home. The assessment information on privately funded residents would benefit from more information in order to ensure that their individual needs are fully met. There has been a marked improvement in this area since the last inspection. EVIDENCE: The files of two residents admitted since the last inspection were seen at this visit. Both had received the benefit of an assessment by the Registered Manager, which had been carried out prior to their admission. On this occasion there was no social work assessment, as both residents were privately funded. The assessment should contain details of all those areas listed in Standard 3.3. A care plan had been compiled for the residents, based on the assessment information. The home does not provide an intermediate care or rehabilitation service. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9 Progress continues to be made on improving care planning. If this progress is maintained there will be good systems in place to ensure that residents’ needs, including their healthcare needs, are identified and met. Medication is generally well administered, although some improvements are required and accredited training has still not taken place. When these requirements have been met residents’ medication needs will be ensured. EVIDENCE: A number of residents’ plans of care were seen during the inspection. These demonstrated that the improvement noted at the last inspection has been maintained. There is room for further improvement and the registered manager acknowledges this. She is currently working on a new format and has already improved the quality of some of the care plans. The new format is promising, but would benefit from greater detail with regard to the process of care, i.e. how the resident likes to be assisted. Care plans seen included risk assessments, but these had not been updated since December 2004. There is no evidence that care plans have been drawn up with the involvement of the resident. Service users’ healthcare needs are noted on their care plans. These include pressure sore risk assessments and falls risk assessments. There is evidence of nutritional monitoring and details of food eaten. There is a system Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 10 in place for weighing residents on a regular basis, but in some cases this had not been done for several months. Daily recording indicated that staff were concerned about the poor appetite of one resident and it was clear from these notes that the G.P. had been contacted for advice. This information, however, could not be cross-referenced to the care plan and there was no plan in place to indicate how this concern was being addressed. A random sample of the medication cassettes and medication administration records were seen. There was one discrepancy. The medicines trolley was cluttered and sticky in places and it is recommended that a larger one is purchased. Controlled drugs are not being stored correctly, although their administration is now being satisfactorily recorded. A medicines refrigerator has been purchased. Staff have taken part in “Nomad” training, organised by the home’s Pharmacist. Although this training is clearly of benefit, staff who administer medication must also receive accredited medication training. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12 Social activities are arranged on a regular basis and particular staff members have taken on the responsibility for organising events. This means that there has been an improvement in the social activities offered. There continues to be room for improvement here as clearly not all needs are being met. EVIDENCE: A number of residents were spoken to during the inspection. In addition the notes of the residents’ meetings were seen. Residents spoken to said that they were able to get up and go to bed when they wished. Residents’ social interests are recorded on their care plans. In house entertainment is arranged and trips out are currently being organised. During the day a number of residents were observed to be enjoying dancing and a singsong. Some residents enjoyed a short holiday at Pontins in the autumn. Specific activities are not arranged for the residents with dementia and it may be necessary to consider specialist activities for this group. Some of the residents said that there had been a lot of noise from those with dementia over the past few weeks. One said: “they keep banging on the tables.” Another said: “It can be noisy, the TV on day and night”. This meant that this resident had stayed in her room more lately. Although food was not inspected on this occasion, a number of residents made very complimentary remarks about the quality of the food. One said: “You can’t grumble at the dinners.” Another said: “The food is not bad at all”. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 12 Some concerns were, however, expressed about the choice at tea-time, particularly the choice for sandwiches. This had been noted in the residents’ meetings and improvements made. One resident said that the staff were obliging and that when she didn’t like the tea-time meal they would make her soup. She did, however, say that on some occasions when she had asked for soup, staff had told her that the “cupboard was locked”. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 and 18 There is a complaints procedure in place and no complaints have been received since the last inspection. There has been no progress on producing a vulnerable adults procedure to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has in place a policy and procedure for dealing with complaints. A record of complaints made is kept. No complaints have been received by the home or by the Commission for Social Care Inspection since the last inspection. Although the home have a copy of the Walsall Social Services Adult Protection Policy and the Department of Health guidance “No Secrets”, they do not have their own policy and procedure on this subject. A requirement that this should be produced was made at the last inspection and has still not been met. Staff training in Adult Protection has not yet taken place. During the inspection the registered manager demonstrated her understanding of the Protection of Vulnerable Adults scheme. There are policies in place with regard to aggression from residents and one staff member gave a good account of how such a situation should be dealt with. The home have not yet drawn up a policy with regard to advice to residents on personal insurance and the preclusion of staff involvement in assisting in the making of or benefiting from residents’ wills. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 25 and 26 The home is generally well decorated and is comfortably furnished. Water temperatures are not checked and regulated, resulting in residents being at risk of scalding. Although many improvements have taken place, the home is let down in some areas of the environment by poor completion. This has meant that some residents have been accommodated in rooms which are not ready for occupation. EVIDENCE: The communal areas, bathrooms and some bedrooms were seen during the inspection. Lounges are in good order and the home was warm and comfortable, with no unpleasant odours. Although there has been progress, not all of the recommendations of the Fire Officer have yet been met. An alarm has now been fitted to the back door, so that staff are aware if a resident leaves by this route. The following areas are in need of attention: Room 29 – carpet is dirty and needs cleaning or replacing. Ground floor bathroom – the bolt should be removed and replaced with an appropriate lock, which can be opened in the event of an emergency. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 15 Room 5 – there is no emergency call point, there is no bedside light, the wardrobe is badly chipped and needs replacing, the toilet has not been fitted in the en suite facility. Room 4 – the en suite facility has not been completed. The room is currently occupied by a resident on respite. It should not have been occupied until all the work was completed. It was noted during the inspection that individual rooms were warmer than they were at the last inspection (when complaints were made by some residents). Despite this, one resident still felt that her room was not warm enough to sit in during the afternoon. She said: “The room is nice, but it really isn’t warm enough. If it was warm enough I could get a nice book and be in the room.” Water temperatures at outlets accessible to residents were found to be excessively high: 51 degrees in the newer part of the building and 58 degrees in the older part. These temperatures place people at risk. The water temperatures had not been regularly tested or recorded. They must be regulated and risk assessed. Not all radiators are guaranteed low temperature surfaces or guarded. The missing tiles in the laundry have now been replaced and the home now has a washing machine with a sluice facility. Dissolvable bags are not being used for soiled laundry. Towels provided to residents were found to be threadbare in some rooms and in need of replacement. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The home employs sufficient staff to meet the needs of its residents. There has been a period of instability, which has affected morale, and recruiting new staff has proved difficult. Staff are, however, enthusiastic and committed and feel that the home will move forward now that a manager has been appointed. Not all of the required recruitment documentation is available in the home. EVIDENCE: There were 23 residents living at the home at the time of the inspection and there were sufficient staff on duty for these numbers. The rota was seen and it indicated that during the morning there are 4 care staff on duty, from 3.00 p.m. to 9.00 p.m. there are 3 care staff on duty, from 9.00 p.m. to 10.00 p.m. this increases to 4 care staff and overnight (from 10.00 p.m. to 7.30 a.m.) there are two waking night staff. A cleaner and a cook are employed each day. The registered manager’s hours are supernumerary. The home continues to make steady progress with National Vocational Qualification training, 12 staff being involved in this training at the present time. The files of two newly appointed members of staff were seen. One file contained all the required recruitment documentation, including copies of Criminal Records Bureau checks and POVA checks. The second did not contain the CRB and POVA checks, but the manager stated that these had been obtained and were currently at Head Office. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 17 Files seen indicated that new staff receives induction training. In addition to the mandatory health and safety training, staff had also received training in tissue viability, Mental Health in later life and the Promotion of Continence. Residents spoken to during the visit made very positive comments about the staff. One said: “The girls work hard”. Another commented that there had been staff shortages recently and said: “It’s been chaos – shortage of staff. Some try very hard – some are the opposite”. “When I was ill they stayed with me ‘til I was alright, when anything goes wrong they will help you.” “The cleaner is very good”. Staff spoken to acknowledged that there had been a difficult period, but they felt that they had pulled together well. Staff said they felt happier now that they had the registered manager in place. Staff were enthusiastic and keen to learn more and progress. One said: “I love my job”. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 The manager is demonstrating good leadership skills, whilst acknowledging the areas in which the home needs to improve. Staff training in health and safety is being better organised, but not all safety checks have been carried out at the required intervals, leaving residents vulnerable. EVIDENCE: A registered manager has recently been appointed to the home. She has worked at the home for some years, latterly in a senior role. The manager is to commence the Registered Managers’ Award and NVQ4 in care in the near future. In addition to the mandatory health and safety training, the registered manager has undertaken periodic training to update her skills. Staff spoken to during the inspection were pleased with this appointment, acknowledging that the home had experienced an unsettled period whilst they had been without a manager. The manager stated that training in fire safety and moving and handling was to be provided in the near future. She is aware that some staff need refresher Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 19 training in first aid and food hygiene. Training in infection control has been arranged for May 2005. The fire alarms are tested weekly. It was found that emergency lighting had not been tested on a monthly basis and that a fire drill had not taken place since August 2004. The registered manager is currently compiling risk assessments on all safe working practice topics. A random sample of staff files seen showed that new staff receive induction training on safe working practice topics, but there was no record of this being followed up with foundation training. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x 1 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x x x x 2 Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard 7 8 8 9 Regulation 13(4) 14(2) 15(1) 13(2) Requirement Residents risk assessments must be reviewed and updated on a monthly basis. Residents weights must be taken on a regular basis and recorded. Care Plans must indicate how particular concerns (such as poor appetite) are being addressed. Controlled drugs must be stored in cupboards meeting the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973 as amended. (Previous timescale of 14/01/05 not met). All staff who administer medication must receive Accredited Training in medication administration. (Previous timescale of 31/01/05 not met). The home must have an Adult Protection Procedure. It must be in line with the Local Authority procedure and the Department of Health guidance, No Secrets. (Previous timescale of 31/01/05 not met). There must be a policy in place on advice to residents on personal insurance and the preclusion of staff involvement in Timescale for action 30/06/05 31/05/05 31/05/05 31/05/05 5. 9 13(2) 30/06/05 6. 18 12(1)(a) 31/05/05 7. 18 12(1)(a) 30/06/05 Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 22 8. 18 13(6) assisting in the making of or benefiting from residents wills. Advocates must be involved in these instances. (Previous timescale of 28/02/05 not met). Staff must take part in Adult Protection Training. (Previous timescale of 28/05/05 not met). All the requirements of the Fire Officer must be met. The carpet must be cleaned or replaced in Room 29. Room 5 must be provided with a bedside light, the wardrobe must be replaced. Room 5 must be provided with an emergency call point. Rooms undergoing refurbishment must not be occupied until the work is completed. Residents rooms must be warm enough for them to use at all times of the day. Water temperatures at outlets accessible to residents must not exceed 43 degrees. Water temperatures must be regulated, risk assessed, regularly checked and recorded. The registered person is required to ensure that all radiators are guarded or have guaranteed low temperature surfaces. (Previous timescale of 28/02/05 not met). Dissolvable bags must be used for soiled laundry. A copy of the homes recruitment policy and procedure must be forwarded to the Commission. (Previous timescale of 31/01/05 not met). The home must ensure that verification of Criminal Records Bureau checks and the Protection of Vulnerable Adults checks are available on the 9. 10. 19 24 23(4) 16(2)(c ) To be arranged by 31/05/05 31/05/05 31/05/05 11. 12. 13. 14. 24 24 25 25 16(2)(c ) 23(2)(b) 23(2)(p) 13(4)(a) 29/04/05 29/04/05 29/04/05 With immediate effect. 15. 25 13(4)(a) 30/06/05 16. 17. 26 29 13(3) 19(1) 31/05/05 31/01/05 18. 29 Care Standards Act S89. Schedule 2 Reg. 7, 31/05/05 Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 23 9, 19. 19. 38 18(1)(c) premises. The registered manager must forward to the Commission a copy of the staff training and development programme for the home. This must include details of training in the mandatory areas of first aid, fire safety, food hygiene, moving and handling and infection control. The home must ensure that there is a person trained to the Appointed Person level in first aid available on each shift. (Previous timescale of 28/02/05 not met.) The home must supply evidence that the person who tests the electrical equipment is competent to do so. (Previous timescale of 31/01/05 not met). The emergency lighting system must be tested on a monthly basis and the findings recorded. Fire Drills must take place at least every six months. The manager must ensure that all staff receive induction and foundation training and updates to meet TOPSS specifications on all safe working practice topics. 30/06/05 20. 38 13(4) 30/06/05 21. 38 13(4)(c) 31/05/05 22. 23. 24. 38 38 38 23(4) 23(4) 12(1) With immediate effect. With immediate effect. 30/06/05 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 3 7 Good Practice Recommendations When assessing privately funded prospective residents, the registered manager should ensure that details are obtained of all those areas listed in Standard 3.3. Residents plans of care would benefit from more information on how the residents likes to be assisted. This E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 24 Shire Oak House 3. 4. 5. 9 12 24 could be obtained by involving the residents in the drawing up of their care plans. It is recommended that a larger drugs trolley is purchased. The home is recommended to give consideration to providing specific activities for those residents in the home who have dementia. It is recommended that an audit is carried out of bed linen and towels. All threadbare towels should be replaced. Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA 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 Shire Oak House E55 S20828 Shire Oak House V223598 260405 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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