Inspection on 27/11/07 for Southwell Court

This inspection was carried out on 27th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Southwell Court 10/11/08

Southwell Court 17/08/06

Southwell Court 17/01/06

Southwell Court 16/08/05

Southwell Court 01/03/05

Southwell Court 17/08/04

Southwell Court 27/02/04

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Paradise Lodge

Bilney Hall

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

CARE HOMES FOR OLDER PEOPLE Southwell Court Hinkins Close Melbourn Near Royston Hertfordshire SG8 6JL Lead Inspector Alison Hilton Unannounced Inspection 27th November 2007 08:50 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 Southwell Court DS0000015167.V355631.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. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southwell Court Address Hinkins Close Melbourn Near Royston Hertfordshire SG8 6JL 01763 262121 01763 262989 Southw@grantahousing.org.uk www.grantahousing.org.uk Granta Housing Society Limited 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) Andrew Tilbrook Care Home 35 Category(ies) of Learning disability over 65 years of age (1), Old registration, with number age, not falling within any other category (35) of places Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named individual in the category LD(E) for the duration of their residency only 17th August 2006 Date of last inspection Brief Description of the Service: Southwell Court is a home for older people. It is owned by Granta Housing Society and is situated on a modern housing estate in the village of Melbourn on the Cambridgeshire and Hertfordshire border. Accommodation is on two floors. Residents are accommodated in 35 single bedrooms, all with en-suite toilet and washbasin. The home is divided into six flats, accommodating either five or six people. Each flat has a sitting/dining area, a kitchenette and an assisted bathroom. The ground floor bedrooms open onto a patio area. A shaft lift or stairs provide access to the first floor. All bedrooms on this floor have access to a covered balcony. There is a large lounge on the ground floor, an activities room and a hairdressing room. The home has large attractive gardens with a pond and seating area. The inspection reports are available in the foyer of Southwell Court. The cost is £364.00 per week for Social Services funded residents and £451.50 per week for privately funded residents. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We (Commission for Social Care Inspection) carried out an inspection of Southwell Court using the Commissions methodology. This report makes judgements about the service based on the evidence we have gathered. The manager completed an Annual Quality Assurance Assessment (AQAA), which was received prior to this inspection. Our evidence also includes an inspection of the home which Alison Hilton, Inspector, made on Tuesday 27th November 2007. The manager or assistant manager was present throughout the inspection. A number of records were seen, together with staff personnel files and files of people living in the home. We spoke to staff and people living in the home during the visit. There were 30 people in the home and two people in hospital. Surveys were sent to those living in the home, their relatives and staff. Those living in the home returned 17 surveys and their comments included “ I like the carers” and “There are often lots of new faces”. Some commented on the lack of staff available to help when needed and that the home did not always smell fresh. Some brought up issues in relation to communication about care. These issues are discussed in the relevant areas in the report. 11 relatives returned the survey and commented: - “Staff appear stretched and in a hurry with care”; 2 people commented that rooms were not cleaned properly and beds not made or changed; “Staff are very kind”; “homely environment”; 3 commented on the variety of activities on offer; one relative likes that family member has the choice of whether to sit in lounge or not. All knew how to make a complaint. Staff returned 19 surveys and commented: - Staffing levels were poor and there was not enough time with people who live in the home. Care plans are completed and staff have access to them. Information is given during handover meetings. Comprehensive training is provided. Contact with the management appears good and staff said they had supervision and appraisals. 1 reply said that they had not completed PoVA, as their job did not require it. What the service does well: People said they had a choice of meals and that these were tasty and very good. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 6 Visitors feel welcome. The provision of activities both inside and outside the home was commented on positively in surveys returned by relatives. What has improved since the last inspection? What they could do better: Care plans must contain information that will allow staff to understand the needs of individuals and how those needs are to be met. Care plans must be kept up to date and take into account changes in physical and mental health. For example weight records alone are insufficient. The home must be able to evidence what actions they are taking if someone has gained or lost significant weight and that these actions have been carried out. Staff must answer emergency call bells to ensure the health and wellbeing of people living in the home is maintained. All staff (including contract workers) must have completed training to protect those who live in the home and to ensure they have the knowledge to do their jobs. The carpeting in the corridors is discoloured, sun damaged and appears dirty when compared to the same carpet in the foyer. There were malodours in one flat during the whole of the inspection. The manager is looking at the issues for individuals living in the flat. The level of need of those living in the home has increased, which means staffing levels need to be reassessed. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 7 The last fire drill was in September 2007 when 11 staff participated. Night staff must also have training so that they know what to do at night. Access to the balcony upstairs is limited for those who have any mobility issues. 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. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 8 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 Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 9 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): 1,2,3,5,6 Quality in this outcome area is good. Information is provided in a suitable format that allows prospective residents to see what the home can provide and whether their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Southwell Court does not provide intermediate care. A copy of the homes statement of purpose and inspection reports on the home are kept in the entrance hall. The home recommends that prospective residents and/or their families visit. They are also sent a brochure and information booklet (now in large print), which includes a request form for information to be provided in a different Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 10 language. Some of those living in the home confirmed that they or their relative had visited. Copies of the homes inspection reports, together with information brochures are available from the foyer in the home. A qualified member of staff completes pre-admission assessments to ensure the home can meet the needs of the person waiting to be admitted. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. Care plans and risk assessments must be completed and the actions required must be undertaken to ensure the health and well being of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) stated “Improvement of Care Plan’s by monthly updates and changes well-documented and ensuring relevance of information on file.” From looking at the files there was a significant difference between the best and worst examples, and although it is acknowledged that staff have different abilities, there should be a level of competency since they are the documents used to provide care. Care plans may be reviewed but if the information written in them is poor this does not get changed or improved upon when reviewed. This was discussed with the manager during the inspection. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 12 Care plans must contain information that will allow staff to understand the needs of individuals and how those needs are to be met. Care plans must be kept up to date and take into account changes in physical and mental health. For example weight records alone are insufficient. The home must be able to evidence what actions they are taking if someone has gained or lost significant weight and that these actions have been carried out. Some weights have not been checked during September and October 2007, and one person had notes on file to be weighed every 2 weeks (22nd July 07) as the result of a significant loss of weight, but according to the records on file she had not been weighed since July 2007. There was also no indication as to whether the dietician had been involved. The AQAA showed a desire to “improve communication between staff and other health professionals by creating ‘champions’ within assistant managers to provide more structured link and referral process”. On speaking to visiting health professionals as part of the inspection, they expressed concern that it is often difficult to find someone in the building, and when they do manage to find a member of staff they “often have no knowledge of the person who requires medical attention as they are from an agency”. The manager commented that he was disappointed that this had not been brought to his attention before. The Medication Administration Record (MAR) charts were seen and had been completed in line with requirements. There were 2 signatures for controlled drugs. People who live in the home said that staff knock on their door and enter, which is what they wanted. People said they were treated with respect. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 13 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. Social activities are organised to ensure some stimulation for people living in the home. Meals are nutritious and balanced and offer a healthy and varied diet for those living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA indicated the home wants to increase the number of minibus drivers where possible. There are still few members of staff qualified to drive the minibus as several long serving staff have recently left. Staff are not required to drive but volunteer. The AQAA showed that the ‘Friends of Southwell Court’ have helped in excursions, which has allowed more residents to be involved in local events such as coffee mornings and village fetes. Several people in the home said their relative takes them out shopping or out for tea. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 14 The activities for the week were displayed in each flat and consisted of Arts and crafts, fashion party, video and sherry, dominoes and the visit by the hairdresser. On speaking to people in the home they said they chose whether to attend the activities, and in many cases did not. They did not know what they would like to do although some said they were happy to remain in their rooms. One lady said she had requested Sky TV for her room but Granta had refused this. A relatives survey showed that the Sky preview connection was an issue that staff had tried to help with but no information about a resolution had been given. The manager said he was awaiting a letter from the person’s daughter with a request for Granta to give further consideration to the request. One person commented that she would like to go onto the balcony when the weather was warm but was unable to gain access to this, as a small ramp would be needed from her room to the balcony. Access to the balcony was a requirement at the last inspection and although the home has made some effort to look into this, since it was brought up by another person living in the home it is being made a requirement at this inspection. The area manager said in response to the report that the possibility of providing access to the balcony for people living in the home was looked at after the last inspection and not found to be possible at this time. This information should be shared with people when looking at the home before admission to ensure they are aware of this. Mealtime observations carried out by the Primary Care Trust Dieticians gave the home a favourable report. The home has one full time cook, one assistant cook and 2 p/t catering assistants. Comments in the surveys showed that people had a choice of meals and that these were tasty and very good. The meals were not seen during the inspection. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 15 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): 16,17,18 Quality in this outcome area is adequate. All staff must complete training to ensure the safety and protection from abuse of those living and working in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA showed that the Complaints and Appeals procedure has been updated by the Society. All resident have been given a copy and others have been placed in the foyer for relatives. The whole staff team receive PoVA training annually. Care staff agreed that they had completed PoVA training and were aware of the types of abuse and that people living in the home can abuse each other. However on speaking to contract workers they said they had not undertaken this training with either their agency or the home. The manager said he would find out why they had not received training and that he would ensure they would as soon as possible. One survey received from a member of staff also said, they had not completed PoVA as “their job did not require it.” Two staff files seen did not have information that would indicate they had completed a PoVA course. All staff (including contract workers) must have completed training to protect those who live in the home and to ensure they have the knowledge to do their jobs. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 16 The complaints procedure has been simplified and the manager ensures all complaints are recorded and dealt with. Senior staff can use their discretion over whether complaints are dealt with and resolved locally or not. All areas are dealt with appropriately and according to Granta’s policy and procedure. People living in the home said they knew where to go to complain and it was evident from replies received in the surveys this was the case, however one person was not keen to do so in case he/she got treated differently. There was no evidence during the inspection that other people who lived in the home felt the same and the policies and procedures are clear that this must not be the case. Staff said that each person in the home is spoken to individually once a month to discuss care plans but also to see if there are any issues. Any issues are taken to a meeting and are discussed and dealt with. On speaking to those who live in the home it was apparent that they felt they received little feedback about decisions and were often not aware of the outcome of their concern /question/ comment. Comments received in the Area Managers feedback indicates that feedback is provided to each resident following their monthly meeting. This is a signed document containing the minutes of the meeting and any issues or concerns raised by them. Any issues that have relevance to all those living in the home might be fed back in a format such as a newsletter so that everyone would know the outcome, but only if the person who raised them agreed. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26 Quality in this outcome area is adequate. The home must be kept clean and odour free to ensure that those who live there are comfortable and safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two kitchenettes have now been upgraded. The stairs to the first floor now have a stair gate fitted to ensure the safety of residents. Details in the AQAA showed that improvements to the grounds have been made and they are now tidy and residents and relatives commented on this. The patio area has been extended making it more accessible to residents. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 18 There are still some people who would like access to the balcony area on the first floor, especially when the weather is sunny. There was an unpleasant odour in one of the flats for the duration of the inspection. The people living in the flat receive a high level of personal care and input in relation to issues of continence. The manager is aware that there is a problem and he is looking at the issues for individuals living in the flat. The carpeting in the corridors is discoloured, sun damaged and appears dirty when compared to the same carpet in the foyer. Ancillary staff were spoken to and they said that each bedroom is thoroughly cleaned once a week with other areas getting a daily hoover and dust. They said that the housekeeper deals with the deep cleaning of carpets when necessary. There are other ancillary staff that were not on duty on the day of the inspection. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. The needs of people living in the home must be reviewed to ensure the care they are receiving can meet them, and that there are sufficient staff to provide the care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been an increase in number of Bank Workers available to the home. Recently staff have resigned or gone sick and after a period of stability with staff this has meant more use of bank/agency staff again. A recruitment campaign is ongoing but Criminal Record Bureau checks are taking a long time. The home currently has 5 ½ whole time equivalent staff vacancies. The manager is recording the amount of staff time taken to escort people to hospital, GP, optician and other appointments as this can have a significant impact on staff cover during the day. In discussion with the manager, staff and visitors it was evident that the needs of the people living in the home are increasing, which means the staffing level may need to be reassessed. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 20 The use of agency staff, which is necessary when there is a shortage of home staff, means that other professionals such as District Nurses have difficulty finding staff with knowledge of the residents needs. Information provided in the surveys from people living in the home, visitors and staff commented that the home is short of staff. Where two staff are needed to hoist any person living in the home this can leave other flats without staff, although there is an emergency call system in place. At the last inspection the rotas showed 4/5 care staff and one manager each morning with 6 beds vacant; currently the rota shows staffing levels with 4 staff and one manager with 3 beds vacant. However on the day of inspection the home was one member of staff short. The manager said there are three staff each evening with an extra member of staff on a 5-10pm shift to assist people to go to bed. All staff (including contract workers) must have completed training to ensure they have the knowledge to do their jobs. This relates to contract ancillary staff completing infection control training. The AQAA showed palliative care training completed by staff. During the inspection we pulled the emergency cord in one of the flats. Although the staff tried to speak to whoever was using the cord we remained silent. This was to check how staff would react and how long it would be before someone arrived to check the seriousness of the ‘incident’. After waiting about 5 minutes we went to find staff whom we had seen entering the neighbouring flat. The staff member was making cups of tea for the flat. When asked if they had heard the alarm they agreed they had. The deputy manager checked the situation and said that the staff member was intending to come to the flat. Staff must answer emergency call bells as quickly as possible to ensure the health and wellbeing of people living in the home is maintained. The home does not keep information on recruitment as this is logged at Head Office. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38 Quality in this outcome area is good. All staff are receiving supervision and appraisals, ensuring staff are aware of changes in policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last fire drill was in September 2007 when 11 staff participated. Night staff must also have training so that they know what to do if a fire occurs at night. The manager said that the Social Services Department contracts monitoring unit had recently inspected the home and the report was positive. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 22 Staff are receiving supervision and appraisals and staff confirmed this during the inspection. The area manager said that Granta Housing Society has an agreement with the Commission that policies and procedures are reviewed every four years. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 23 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 X X 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12 (1) Requirement Care plans must contain information that will allow staff to understand the needs of individuals and how those needs are to be met. The balcony from the first floor rooms remains inaccessible to people living in the home who may wish to go out. The home must ensure that those who wish to go on the balcony have the means to do so. This requirement is carried over from the last report with the timescale not being met. All staff (including contract workers) must have completed training to protect those who live in the home. The home must be pleasant and clean to ensure the well being of people living in the home. The carpeting in the corridors is discoloured, sun damaged and appears dirty when compared to the same carpet in the foyer. This does not provide people living in the home with homely comfortable surroundings. DS0000015167.V355631.R01.S.doc Timescale for action 01/04/08 2 OP12 23 (2)(a) 01/04/08 3 OP18 15 (6) 31/01/08 4 5 OP26 OP26 16 2(k) 23 (2) (b) 01/03/08 01/04/08 Southwell Court Version 5.2 Page 25 6 OP27 18 1(a) 7 OP30 18 1 (a) 8 OP30 18 1 (c) The number of staff on duty must take into consideration the changed needs of those living in the home to ensure their needs can be met. Staff must answer emergency call bells appropriately to ensure the wellbeing of people living in the home is maintained. All staff (including contract workers) must have the training necessary to do their job competently to ensure the well being of those living in the home. 01/01/08 27/11/07 31/01/08 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 OP38 Good Practice Recommendations It would be good practice to ensure that all night staff are involved in a fire drill to ensure they know what to do in the event of a fire at night. Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Southwell Court DS0000015167.V355631.R01.S.doc Version 5.2 Page 27 - 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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