Inspection on 21/04/05 for Southfield

This inspection was carried out on 21st 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 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

Southfield 17/07/07

Southfield 23/05/06

Southfield 02/11/05

Southfield 20/12/04

Southfield 05/07/04

Southfield 12/02/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Poldhu

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

CARE HOMES FOR OLDER PEOPLE SOUTHFIELD Victoria Road Devizes Wiltshire SN10 1EY Lead Inspector Roy Gregory Unannounced 21st 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. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Southfield Address Victoria Road Devizes Wiltshire SN10 1EY 01380 723583 01380 728647 manager.southfield@osjctwilts.co.uk The Orders of St John Care Trust 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) Vacant (application pending for registration of current manager, Val Weston) Care Home 42 Category(ies) of 12 DE(E) Dementia - over 65 registration, with number 1 LD(E) Learning dis - over 65 of places 8 MD(E) Mental Disorder - over 65 42 OP Old Age 2 PD(E)Physical dis - over 65 SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 20th December 2004 Brief Description of the Service: Southfield is a purpose-built residential home for 42 older people, some of whom may have dementia or be experiencing mental health difficulties. The home was formerly owned and run by the local authority, but has for some years been provided by the Orders of St John Care Trust, one of a number of homes provided by them in Wiltshire and elsewhere. Accommodation is all in single rooms, located on two floors, with a passenger lift to the first floor. All bedrooms have wash hand basins, but none have en-suite facilities. Toilets and bathrooms are located conveniently. There are sitting rooms on each floor, whilst behind the home are extremely attractive and secure gardens, including a patio area. The dining room overlooks the gardens. The home is located in a residential area a short walk from Devizes town centre, where shopping and social facilities are available. There are good bus links to neighbouring towns, whilst the home has its own adjacent car park. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9:10 a.m. and 5:35 p.m. on Thursday 21st April 2005. The inspector spoke at length with seven residents, including sharing lunch in the dining room with two of them. The manager being absent at a county managers’ meeting, the inspector received helpful guidance, including access to documentation as required, from the administrator and the care leaders on duty. Additionally there were conversations with care and housekeeping staff. The inspector had the benefit of meeting with three visiting relatives. Since the inspection, the inspector has been able to share findings with the manager, Val Weston, by telephone. The inspector selected a number of care plans to compare observations of care with written records. Other records consulted included those relevant to recruitment, staffing and health and safety. Most of the building was visited and a number of individual rooms were seen with the consent of their occupants. There was also a visit during the day by the specialist pharmacist inspector, who reviewed the home’s procedures for handling medications. Her findings are reflected in this report. What the service does well: What has improved since the last inspection? The provider has completed a programme of making all radiators safe, and planned work was in progress on making the bar and nearby sitting room more attractive, which will widen residents’ opportunities to socialise. Care plans now include assessments for risk of pressure sores, as required at previous inspection, and these showed they were regularly reviewed and that risks are brought to the attention of district nurses. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 6 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. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.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 SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.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 & 4 (n.b. key Standard 6 is not relevant to Southfield as Intermediate Care is not provided) There is a clear admissions policy in place. Residents’ needs are assessed prior to placement. Assessments are comprehensive and detailed, enabling residents and their supporters to have confidence in the home’s appropriateness to meet their needs. EVIDENCE: The inspector spoke with a resident whom he had met as a recently admitted service user at the previous inspection. The person considered the home to be providing the service they had anticipated through the assessment and admission process. Their care plan confirmed that comprehensive information gathered at initial assessment was used to start off the care planning process. A resident staying for three weeks’ planned respite care conveyed a full understanding of the reasons for their stay in the home, and their care plan showed an initial assessment had been undertaken. This in turn led to the most important care needs being highlighted in the care plan. This person had the advantage of familiarity with the home through prior regular attendance at the attached day centre, which is the case for many of Southfield’s residents. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 9 SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 10 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, 9 & 10 Care plans direct care and receive regular review. Residents’ health needs are met. Manual handling and pressure area risk assessments, whilst good, are not linked sufficiently to care planning to minimise areas of potential risk. Residents value provisions made for their privacy. Systems for administration of medications have not prevented errors being made. EVIDENCE: Residents did not generally have much knowledge of, or interest in, their care plans as written documents, but all were confident that staff were observant of and attentive to any health issues. Care records and observations confirmed this to be a strength on the part of care staff. Care plans reflected well the people they were about, and gave good guidance to care staff in respect of both physical and social needs. There was much evidence of regular reviews, with resultant changes and additions as appropriate. Pressure area risk assessments were of a good quality, having been made a specific responsibility of one care leader, and they were being reviewed regularly. It remains the case, however, that these assessments should be reflected in short term care plans, even where the district nurses are the main providers of care. It was also noted that a respite resident, whose assessment would have indicated a high risk, had yet to be assessed. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 11 Some residents had specific care plans for regular weighing, but not all such plans were being adhered to. Where residents were weighed, whether or not as a result of a plan, it was not clear why, nor who took responsibility for monitoring them, neither were weights being recorded consistently in one part of the care plan. The pressure area risk assessments, or manual handling assessments (which were excellent) might represent good locations for this information. The inspector heard many expressions of appreciation of staff attitudes, and observed instances of respect for privacy. One resident said her room was very much her home, where staff came in on her terms, whilst another spoke of doing what she wanted and staff fitting around that. Evidence was seen of the home’s appropriate intervention in self-medication and medicines brought in by relatives. With regard to receipt, storage and administration of medicines, the pharmacist inspector was able to recommend ways in which systems may be made less cumbersome, and thus less at risk of errors, the home having notified a number of medication errors during the previous year. There is also a role for the supplying pharmacy to assist the home. Cold storage for medicines requiring this was unsatisfactory, although the manager has subsequently informed the inspector a suitable refrigerator has been provided. The practice of disposing of needles from insulin injections did not ensure staff safety. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 12 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, 13 & 15 Contacts with the wider community are supported, whilst the home is actively addressing how to supplement activities currently available through the attached day centre. High quality meals are served, with due regard to individual nutritional needs. EVIDENCE: Many residents retain strong links with activities and clubs in the community. Within the home, there is largely reliance upon the attached day centre for provision of activities, which residents are welcome to join in as they choose, and many did so on the day of inspection. Some residents expressed a view that those without active family support nearby were missing out on opportunities to go outside the home. This had been identified by management through residents’ meetings and other quality assurance channels, such that plans were in hand to make short trips into the surrounding area. One resident bemoaned the fact that when activities were organised, there was too little interest from residents themselves. The home was currently advertising to recruit an activities co-ordinator, which will promote opportunities to identify and meet individual and group needs for physical and social stimulation, whilst the bar area of the home was in process of receiving a facelift. There was agreement by residents and visitors that visitors enjoy ready access to the home, seeing residents in private rooms or communal areas as they choose. It was evident that some residents receive regular support from their churches. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 13 Residents were overwhelmingly complimentary of meals in the home. The midday meal offered a hot choice and a cold option, with a choice of three sweets. All choices are made at table. Residents were aware that further choices were welcome with notice. Service in the dining room was friendly and efficient. Care plans showed attention to individuals’ nutritional needs, and this information was clearly shared with the catering staff. The chef spoke of making changes in the menu in response to residents’ wishes. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 14 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, 17 & 18 Complaints receive appropriate investigation and action. Civic rights are recognised and protected. The home has been pro-active in using local interagency adult protection procedures. The staff group are lacking in abuse awareness training. EVIDENCE: The complaints record was well laid out and showed that complaints of any magnitude received detailed consideration. Apologies were tendered where indicated, and learning points translated into care plans and reminders to staff of means to improve services. Some complaints were investigated by higher Trust management, in line with the Trust’s complaints procedures. Residents were well informed about the means to raise complaints, formally or informally, although a visitor regarded their relative and others as reluctant to do so. Many residents had received polling cards for the forthcoming general and local elections. The administrator said assistance would be arranged as necessary to facilitate polling station attendance, for example by ordering taxis and providing staff accompaniment, whilst he had arranged postal votes for a number of residents who had requested this. Information about an advocacy service was on display. Where necessary, the home has referred matters into local inter-agency vulnerable adult procedures, and co-operated with enquiries generated by that forum. Training records showed very few staff had received abuse awareness training, although induction of new staff includes awareness of guidance to the local procedures. Visitors’ entry to and exit from the home are monitored by staff. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 15 SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 16 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 -21 & 23 - 26 There was generally good attention to provision for safety, but there were shortfalls in maintaining décor and levels of cleanliness, which concerned residents and visitors visually as well as posing infection control risks. Provision of communal facilities was good and appreciated by residents. Bedrooms and corridors displayed a lack of imagination and colour, although residents have made themselves very much at home in personal rooms, with much use of personal possessions. EVIDENCE: In places the home shows its age and there are a number of decorating needs. The home has not been helped by being without a handyman for the past year, a problem being rectified at the time of inspection. A resident had had a new radiator installed in their room last year, but this had left part of the wall with no wallpaper and unsightly stains. Each of the bedrooms contains a standard built-in wardrobe and vanity unit, finished in gloss paint, which gives an unwelcoming and tired feel. In many of the rooms seen, the wash hand basin was fronted by extremely worn and bare wood, which cannot be adequately cleaned. In one room, this wood had been replaced by a modern impervious material. Standards of cleaning were poor, with considerable dust on surfaces SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 17 such as bedside lockers, pictures, and skirtings where these were overlaid by pipes, such as in toilets and bathrooms. Some residents said their only complaint about the home was to do with cleaning of toilets, an important issue in the absence of en-suite provision. The inspector found sanitary ware itself to be clean. The manager has informed the inspector that additional housekeeping hours are to be provided. Records show some residents can be disorientated in corridors, especially at night, resulting sometimes in falls or intrusion into wrong rooms. A resident said this had been a problem for her when she had first moved in, until relatives put a picture on her door. Corridors are not well lit, and have a succession of similar coloured doors. Toilet and bathroom doors benefit from written signage. Communal rooms were homely and comfortable. Residents considered lounges, the dining room and garden to be assets of the home, and were generally content with personal rooms. Some had brought furniture of their own and most had televisions. Dining furniture was old and worn, but was said to be due for replacement in the near future. Bathrooms had some good homely touches. The bar and small lounge opposite were being redecorated. The laundry presented as clean and organised. A visitor said their relative’s clothes were sometimes washed in inappropriately mixed loads, and that delivery could be haphazard. Staff meeting minutes showed the previous manager had addressed such matters with staff. The inspector was struck by the ragged nature of hand towels being distributed to residents’ rooms. Use of sluices appeared safe, but in the upstairs sluice room there was a bare concrete plinth that needed to be sealed in order not to be a dirt trap in a highrisk location, and the area under the sink was unclean. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 18 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, 29 & 30 Satisfactory staffing levels are maintained, and residents experience care staff as competent and very caring, although somewhat rushed. Staff benefit from ongoing training, which is geared to the identified needs of residents. The process of staff recruitment ensures that all the checks and references necessary to protect service users are in place. EVIDENCE: Rotas showed that by day there were always at least four care staff on duty, including a care leader, whose duties are in part office-based. On weekdays, half of day shifts benefited from an extra carer on duty. The care leader responsible for the rota said that staff were very helpful in covering for each other’s leave and training absences, although weekends could be problematic. In respect of one resident there is a care package under which extra care is provided from outside. Residents were very pleased with the approach of care and other staff to their work, but for a common observation that staff had little time to simply sit and talk. There was appreciation that staff were always made available, if required, to accompany residents to appointments outside the home. It was evident to the inspector that staff used interactions such as giving out drinks, to engage with residents and to observe wellbeing. Since previous inspection the home had recruited one new member of staff. Records for this were thorough, in accord with required regulations. The home has experienced difficulties recruiting kitchen staff and a handyman. There were plans in hand to increase the housekeeping staff, and possibly to add some cleaning duties to night care staff by changing the present complement of two waking staff and a sleep-in care assistant, to three waking staff. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 19 Training records were clear and easy to track. The provider Trust demonstrates that training is encouraged. About half of care staff had received dementia training within the past 18 months. Less than half had been involved directly in pressure area care training, although there were indications this was shared through the staff group. Observations of care-giving, combined with the quality of care notes and evident liaison with outside agencies, gave a picture of a competent and committed staff group. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 20 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) 33, 37 & 38 There are some systems in place to enable residents’ consultation, but these are insufficient to reassure residents and their supporters that their views can make a difference to how the service is delivered. Record keeping is of a standard that protects residents’ rights and interests. Health & safety monitoring is good, but the lack of previous attention to guarding hot pipes places service users at risk. EVIDENCE: There had been a residents’ meeting in March 2005. Minutes showed that a wide variety of matters were discussed, including residents’ requests for outings and for room decorating. However, there was no record of who attended the meeting, or what was to be done about issues raised. The previous recorded residents’ meeting was in August 2004, with no indication to the recent meeting of whether or how matters raised had been addressed. A home newsletter has been commenced, and this could be developed as a channel for communication available to all and dovetailing with meetings. Residents were not confident that it was always worthwhile to air comments or SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 21 wishes. A visitor thought that a relatives’ group would be well supported and could both advocate for residents, and provide material assistance to Southfield. The home had a certificate for having recently achieved a recognised quality assurance standard. This put some emphasis on the home’s adoption of a new series of policies and procedures introduced by the provider Trust. Included is the complaints procedure, use of which showed that complaints were used constructively to improve the service to residents, individually and generally. Records of monthly provider visits show that residents are routinely spoken to, and identified issues brought to the manager’s attention. Record-keeping was orderly, secure and of good quality. A recent visit by the Fire Officer found the home to be complying with fire regulations, although it had been suggested that fire-resisting shutters could be considered between kitchen and dining room. All fire precautions records were up to date. The home had completed a programme of making all radiators safe to touch, but some exposed very hot pipes remained to be covered. The administrator showed that this work was programmed, and the manager subsequently agreed to take urgent temporary action in one location, where a hot pipe might be used by a resident as a grab rail. The provider Trust has good arrangements for routine health & safety checks and maintenance, whilst risk assessments are revisited as appropriate. SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 22 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 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 3 2 2 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 2 x x x 3 2 SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 23 no 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. Standard 7, 8 Regulation 12 (1)(a) Requirement Pressure area risk assessments must be completed soon after admission, including for respite service users, and identified risks must be reflected in short-term care plans. There must be a planned frequency of weighing for each service user, and weights must be recorded in a consistent manner. Medication that requires cold storage must be stored securely at the appropriate temperature. Staff must receive training in the appropriate manner to dispose of needles to ensure that they are not put at risk of needle-stick injury. Where wash hand basins have a bare wooden surround, this must be replaced by an impermeable material. Cleaning schedules must pay attention to regular dust removal. The bare concrete plinth in the upstairs sluice must be sealed with an impermeable finish. Regular consultation with service users must be enabled, ensuring Version 1.30 Timescale for action 31st May 2005 2. 8 12 (1)(a) 31st May 2005 3. 4. 9 9 13(2) 18(c)(i) 31st May 2005 30th June 2005 5. 26 13 (3), (4)(a) 13 (3) 13 (3) 12 (3), (5) 30th June 2005 31st May 2005 31st May 2005 30th June 2005 Page 24 6. 7. 8. 26 26 33 SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc 9. 38 13 (4)(a,c) all meetings are recorded to include details of attendance and of actions ensuing from service user consultations. Exposed hot pipes must be made 31st May safe from presenting risk of burn 2005 injury. 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 18, 30 19, 24 Good Practice Recommendations Abuse awareness training should be given greater priority in the staff training programme. Decorating needs should be prioritised in a written plan, in consultation with service users and to include making good of areas and fittings that present possible compromises to adequate cleaning. The provider should consider how bedrooms could be made more individual and modern. Consideration should be given to use of colour, lighting or signage to reduce the risk of disorientation by service users in corridors. Opinions should be canvassed about the possibility of establishing a supporters group. Frayed and worn towels should be replaced. 3. 4. 5. 6. 23, 24 19, 25 33 25 SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB 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 SOUTHFIELD D51_S28318_SOUTHFIELD_V221990210405Stage4.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. 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