Inspection on 05/12/07 for Silver Howe

This inspection was carried out on 5th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Silver Howe 24/09/08

Silver Howe 10/01/07

Silver Howe 21/03/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Silver Howe Dalton Drive Sedbergh Road Kendal Cumbria LA9 6AQ Lead Inspector Ray Mowat Unannounced Inspection 5th December 2007 09:00 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 Silver Howe DS0000066837.V352855.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. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Silver Howe Address Dalton Drive Sedbergh Road Kendal Cumbria LA9 6AQ 01539 723955 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) Hometrust Care Limited Miss Tamara Louise Hope Care Home 30 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (30) of places Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is: 30. Date of last inspection 10th January 2007 Brief Description of the Service: Silver Howe is a large detached Victorian building, set in its own grounds in a quiet residential area, on the outskirts of Kendal, Cumbria. It is accessed by a private road at the end of a cul-de-sac. Public transport is within walking distance and the town centre is approximately a mile away. Silver Howe is registered to provide residential care to thirty older people, including people with dementia. The home is on three floors, which are accessed by a passenger lift or one of the two staircases. The top floor is used by staff and provides private living accommodation. There are four lounge areas on the ground floor, and one on the first floor with two dining areas, one for each floor. The home provides a good range of adapted bathing/shower and toilet facilities. There is parking to the front of the building with wheelchair access to the side door. The grounds and gardens are attractively landscaped and well maintained. To the rear of the home there is ramped access to both the garden and patio areas. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 5 The home provides information to residents and prospective residents in an informative brochure and service user guide, which are regularly updated. The current fees charged range from £397 to £440 depending on the size of the room and its facilities, with additional charges for personal sundry expenses such as hairdressing. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit took place over one day. During the visit we (The Commission for Social Care Inspection) met with many of the people living in the home either in small groups or on their own, we also joined a group of people for lunch in the downstairs dining room. We spent time with the acting manager, a visiting Operations manager and several of the care staff on duty, including individual discussions, as well as talking to them as they went about their duties. As part of the inspection we sent out a selection of surveys to people living in the home, their relatives, care staff and other professionals. We examined records relating to the management of the home that are required by legislation as well as personal information about the care and support people require. The evidence gathered during the above activities and supplied by the manager prior to the visit, in the Annual Quality Assurance Assessment (AQAA), has informed the judgements made in this report and the overall quality rating of the home. What the service does well: People are given good information before making a decision to move into the home and agree a clear contract about the rules for living there. All the care plans examined had been reviewed on a regular basis including a good range of risk assessments ensuring people are safe at all times. Staff have developed good relationships with people and there is a mutual respect and understanding. As one staff described “we give people space and they take responsibility, which gives them pride”. One person living in the home described the staff as “very caring”. Over 50 of staff in the home have gained at least NVQ level 2 or above, with some staff now working toward their NVQ 3, which is good staff development. Some staff have completed training in palliative care, which gives them the skills and knowledge to provide appropriate care and support. All medication was securely stored including extra security and recording for controlled drugs in line with good practice. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 7 The introduction of a “family tree” record, has improved the information relating to important events, relationships and friendships in people’s lives. A good choice of activities and social events are taking place that people are enjoying. The home is clean and well maintained and provides people with good private and communal space. There is a relaxed atmosphere in the home with staff and the people living there enjoying good relationships. People feel “safe and well cared for”. The menus are varied and provide healthy options, with special diets and requests catered for. The management provide good supervision and support to staff, who feel a “valued part of the team”. Staff talked about being “well supported by senior staff” and the manager being “very approachable”. What has improved since the last inspection? What they could do better: Staff, including volunteers, must not be appointed or confirmed in post until satisfactory checks (CRB and POVA) and references have been obtained. This will help to ensure that people living at the home are protected from the risk of harm. Assessments should clearly identify the care and support needs and reflect the preferences and choices of people using this service. All care plans should be developed based on the comprehensive pre-admission and dependency needs assessment to ensure a consistent and responsive service is provided. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 8 A record of all medication coming into and leaving the home should be in place to enable an accurate audit to take place. The recording of PRN (as and when required) medication. Should be clear, with instructions about, why the medication has been prescribed, how much and when it should be given. All staff working in the home should complete dementia awareness training and individual staff training records should be updated to ensure appropriate training is planned to meet the individual needs of 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. The summary of this inspection report can be made available in other formats on request. Silver Howe DS0000066837.V352855.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 Silver Howe DS0000066837.V352855.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are given good information about the home enabling them to make an informed choice about moving in, however the assessment process should be more consistent to make sure all relevant information is recorded. EVIDENCE: A new brochure has been produced by the organisation to make sure people are given relevant information to enable them and their representatives to make informed decisions about moving into the home. People we spoke to during this visit and who completed surveys confirmed they were given “a lot of information” and said “all our questions were answered”. Information was also available in the home and displayed on notice boards. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 11 A clear contract of terms and conditions is agreed and signed by the person or their representative when they move into the home. These include detailed information about fees and additional charges, policies of the home including complaints and the key terms and conditions of residence. It also explains the terms of the probationary period at the start of a contract. The quality and depth of care needs assessments are inconsistent with some lacking detail about personal care needs. The assessments should clearly identify the care and support needs and reflect the preferences and choices of people using this service. This information should then be used to develop a personalised care plan. Based on discussions with the manager she was aware of the skills and resources of the home and when carrying out assessments the need to ensure the home can safely accommodate and respond to people’s diverse needs. The recording of this process should be strengthened. Silver Howe DS0000066837.V352855.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All care plans should be developed based on detailed assessments of need and be sufficiently detailed to guide and support staff in providing a consistent and personalised package of care. EVIDENCE: Improvements have been made in relation to the regular monitoring and review of care plans, with all the care plans examined being reviewed on a monthly basis. In addition a day/night report book is now completed at the end of each shift to record key events that require further action or monitoring and impact on the plan of care. This has improved communication between the teams of staff and management and ensures any changes in need are recorded and responded to. A new key work system has also been introduced, which involves the person, their family or representative working more closely together, to ensure individual needs are identified, recorded and responded to. This could involve making sure the room and furniture are suitable and safe, clothing needs or any aspects of personal care are being attended to appropriately. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 13 The staff also work closely with a number of health care professionals such as the Community Mental Health team and Intermediate care team to ensure people are receiving the support they require. The introduction of a “family tree” record, has improved the information relating to important events, relationships and friendships in people’s lives, as well as social interests and hobbies. This has helped the home to develop a varied range of activities that interests the people living in the home. Daily care notes completed by staff are also an important part of the care plan that record significant events and changing needs or routines. Health care needs are recorded separately and included a record of visits to the GP or Consultants and a record of ‘collaborative care’, where the home is working with other agencies such as Social Workers, Community Psychiatric Nurse or Intermediate Support teams. The range of risk assessments that have been completed and regularly monitored has also improved and included falls, pressure care, moving and handling and general risks. The care plans need to be strengthened so that they are a cohesive document that will guide and support staff in meeting all personal and healthcare needs based on a thorough assessment. Based on the examination of the assessments and care plans during this visit and discussions with the manager and care staff, this is still not happening consistently, with some plans only detailing some key aspects of care. We examined some medication records against the medication held by the home. On the whole these were up to date and accurate, however the recording and monitoring of medication coming into or leaving the home should be reviewed to ensure an accurate audit can take place. All medication was securely stored including extra security and recording for controlled drugs in line with good practice. All the staff involved with the administration and handling of medication have received suitable training from the supplying pharmacist, which checks out their competence. The other area that needs to be strengthened is the recording of PRN (as and when required) medication. There should be clear instructions about, why the medication has been prescribed, how much and when it should be given. Care plans record people’s wishes if they fall ill or are dying, also recording family involvement and preferences. Some staff have completed training in palliative care, which is good practice. Silver Howe DS0000066837.V352855.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is now providing a good range of social activities and events to meet the diverse needs of the people living in the home. EVIDENCE: There have been great improvements in the assessment, recording and provision of social activities for people. Consultation has taken place regarding people’s preferences in addition to the completion of the ‘family tree assessment’, which records past and present interests, hobbies and social contacts and interests. The organisation has also been successful in gaining Care Sector Alliance funding for a project to promote ‘diversity, quality and choice through social activity’. This money is being used to fund sessions with an Occupational Therapist who completes assessments of people’s abilities and interests to produce an ‘activities profile’ for each person. They also work closely with staff training them in delivering appropriate activity sessions to meet their needs. These have included activities relating to daily living skills, memory games, reminiscence, a music group and a ‘falls group’. This includes looking at the causes and prevention of falls, exercises, and counselling and advice regarding the affect of falls. This is an innovative scheme and an example of good practice. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 15 The home has also appointed a part time activity coordinator who works four hours a day, Monday to Friday, to facilitate and organise both social and therapeutic activities. Based on the results of the consultation regarding activities they have developed a varied daily programme of sedentary and nonsedentary activities. These range from tabletop games or crafts to more active armchair keep fit sessions or gardening. People are appreciating this new development, which is a credit to the commitment and enthusiasm of the staff that support it. Based on our observations and discussions with the people living in the home and staff people are “enjoying the activities and events”. Displayed on the notice board was a number of forthcoming Christmas events and activities including a pantomime show, which people were looking forward to. Consultation had also taken place about the food and menu choices. A three week rolling menu was displayed in the home providing a good selection of nutritious meals. People have a good choice of food at each meal and they confirmed that the “Chef will provide an alternative if we request it”. The lunchtime meal options were healthy and balanced and provided a contrast, there was also a good selection of desserts and fresh fruit was offered after the meal and throughout the day. People spoken to were complimentary about the food and said how nice mealtimes are, “we always have a chat”. Silver Howe DS0000066837.V352855.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People feel their views are listened to and any issues or concerns are dealt with appropriately. All incidents are recorded and responded to. EVIDENCE: The home has a suitable complaints policy and procedure in place, which is included in the service user guide and contract of terms and conditions and is also displayed in the foyer of the home. There have been four complaints in the last twelve months, all of which were responded to in 28days including 3 that were resolved in that time. The home has a very open policy to complaints and people spoken to say, “the staff always listen and help”. In addition to listening to individuals the manager facilitates “residents and relatives meetings” on a regular basis, which provides people with a forum to raise any issues or concerns at an early stage. The introduction of the key worker system will enhance and improve open communication. Staff have recently completed training in relation to Adult Protection procedures, including the manager who has completed the ‘training the trainer’ course, enabling her to provide further training. The new induction course also includes Adult Protection sessions. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 17 Staff spoken to were aware of what constitutes abuse and their responsibilities in identifying and reporting incidents and safeguarding people. The home’s policy and procedure should be reviewed to ensure it is up to date and in line with local procedures and changes in legislation. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, decorated and furnished to a good standard. People feel at home in a safe and comfortable environment that meets their needs. EVIDENCE: A quality improvement and refurbishment programme is in place, which will ensure the home environment and grounds are maintained to a suitable standard. The home and grounds are accessible with ramped access and a passenger lift to assist people. The home employs a handyman who takes a lead role in monitoring the maintenance and servicing of equipment and services. All areas of the home we examined were well maintained, clean and hygienic with good quality furnishings and fittings. The domestic staff hours have increased to maintain Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 19 this standard. Both people living in the home and staff commented on the “clean and homely” environment. The bedrooms we inspected were personalised with residents having their own furniture and belongings around them, which is important to them and gives them a homely feel. The new front entrance has improved access to the home with other alterations also enhancing the environment. Thought has been given to making the environment more accessible to people with dementia with appropriate use of colours and signs, which is good practice. There were suitable aids and adaptations around the home to help people to maintain and promote their independence. The home works closely with other agencies to ensure specialist needs are catered for. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff recruitment procedures must be strengthened to ensure people are safeguarded and staff are suitable for their role. EVIDENCE: Although the home has experienced some difficulties with staff recruitment sufficient staff were on duty to meet the care needs of people living at the home. The recruitment of a new activity coordinator has had a positive affect and improved people’s experience of the home. The staff personnel files of all the people employed since the last inspection visit were looked at. Not all the files contained completed application forms and previous employment histories. Written references and criminal record bureau checks (CRB) and protection of vulnerable adult list checks (POVA) should be in place for each member of staff. Three of the seven files we examined contained only 1 reference, 4 did not have a POVA check and 4 did not have a CRB disclosure. Three of these were overseas staff who did have a police check from their country of origin. Employing staff before the manager has full information about them could place people using this service at risk from harm. This is subject to a requirement. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 21 Regular staff meetings take place with minutes of the meetings recorded. The meetings have an open agenda with management encouraging staff to raise issues. The information sharing at the meetings helps to maintain a good continuity of care. Staff spoken to confirmed “We are a good team, it’s a friendly place we care about what we do”. Staff talked about being “well supported by senior staff” and the manager being “very approachable”. There was evidence of regular supervision taking place on a monthly basis, which is good practice. Staff confirmed that training is provided and specific training requests responded to. A staff training plan for the year has been developed including core training subjects and some specialist areas, however this did not include dementia training, which should be a priority for the home. The new induction training programme has been well received by staff and has been effective in providing them with suitable skills and knowledge for their role. Individual staff training records were examined, which are in need of updating to ensure appropriate training is planned to meet individual needs. Over 50 of staff in the home have gained at least NVQ level 2 or above, with some staff now working toward their NVQ 3, which is good staff development. Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is providing good leadership and support and ensures people who live and work in the home are contributing to all aspects of home life. Areas for development have been identified and responded to. EVIDENCE: Currently an acting manager, due to the long-term absence of the registered manager, is managing the home. She is suitably qualified and experienced for the role and is providing good leadership and support to staff. Through regular ‘residents’ meetings and staff meetings people are able to contribute to the running of the home, they are involved in decision making and feel their contributions are listened to and valued. People have been Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 23 formally consulted over specific issues such as activities and menus and the home is developing a new annual quality assurance assessment. Staff described the home as “flexible, people have choices their views are valued”. The home has suitable policies and practices in place to safeguard people’s financial interests when people require support and will only act as an agent when no one else is available. The manager has introduced monthly supervision for all staff, which is recorded. This provides them with an opportunity to raise any issues or concerns, practice issues, training and development needs and ensure a continuity of care is maintained. Staff spoken to appreciate this support and feel it helps “good communication between management and staff”. Based on the information supplied in the AQAA and from our examination of policies and procedures on this visit, it is recommended the home’s policies and procedures are reviewed and updated as required in line with new legislation. Good systems are in place to ensure the home is safe and comfortable. Routine health and safety checks and servicing of equipment are taking place in a timely manner. Risk assessments are in place and kept under review on at least an annual basis. A new fire risk assessment has been completed in line with the new fire regulations. Silver Howe DS0000066837.V352855.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 3 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 2 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 3 Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 18, 19 Requirement Staff, including volunteers, must not be appointed or confirmed in post until satisfactory checks (CRB and POVA) and references have been obtained. This will help to ensure that people living at the home are protected from the risk of harm. Timescale for action 01/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations Needs assessments should clearly identify the care and support needs and reflect the preferences and choices of people using this service. All care plans should be developed based on the comprehensive pre-admission and dependency assessment to ensure a consistent and responsive service is provided. 2 OP7 Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 26 3 OP9 A record of all medication coming into and leaving the home should be in place to enable an accurate audit to take place. The recording of PRN (as and when required) medication. Should be clear, with instructions about, why the medication has been prescribed, how much and when it should be given. All staff working in the home should complete dementia awareness training. Individual staff training records are in need of updating to ensure appropriate training is planned to meet individual needs of staff. The home’s policies and procedures should be reviewed and updated as required in line with new legislation. 4 OP9 5 6 OP30 OP30 7 OP37 Silver Howe DS0000066837.V352855.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Silver Howe DS0000066837.V352855.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. 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