CARE HOMES FOR OLDER PEOPLE
St Huberts Lodge St Huberts Road Great Harwood Lancashire BB6 7AR Lead Inspector
Mrs Janet Proctor Unannounced Inspection 09:30 17 and 18 November 2005
th th 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 St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 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. St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Huberts Lodge Address St Huberts Road Great Harwood Lancashire BB6 7AR 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) 01254 888581 01254 872685 Mr Thomas Cardwell Mrs Selina Cardwell, Mr Ian Cardwell Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th April 2005 Brief Description of the Service: St Huberts Lodge offers care to 13 older people. The building is a large detached house, which has been converted into a care home. It is situated in a residential area of the town of Great Harwood. Opposite the home is a Catholic Church. It is within walking distance of local shops and the town centre. The bedrooms are 50 single and 50 shared, most without en-suite toilets. A hand wash basin is present in all bedrooms. There is one communal toilet on the ground floor and 2 communal bathrooms, with toilet, and 1 communal toilet on its own, on the first floor. There are 2 communal lounges with dining facilities. The first floor can be accessed via a passenger lift. Ramped access is available to the front entrance. Car parking is available to the rear of the home. St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one and a half days on the 17th & 18th November 2005. The previous inspection was done on 19th April 2005 and information on the findings of this can be obtained from the home or from www. CSCI.org.uk . No additional visits have been made since the previous inspection. On the days of the inspection there were 12 residents at the home. Information was obtained from staff records, care records, and policies and procedures. Information was also got from talking to 7 service users, the Manager, the Deputy manager, 3 staff members and 2 visitors. Wherever possible the views of residents were obtained about their life at the home. Detailed notes were taken, which have been retained as evidence of the inspection findings. What the service does well: What has improved since the last inspection?
The written information for staff about reporting suspected abuse was now clear. The procedure was on display in the hallway so anyone could read it. This meant that the staff, or anyone else, had good directions on what to do if they suspected abuse was occurring. The amount of training arranged for staff had increased. All staff members had done moving and handling training. This meant that they were now aware of
St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 6 the correct method of moving people. Documents to show training and qualifications were now kept in the files of the staff members. This meant that the manager had a current record as to what training had been done by staff. Thorough risk assessments had been done for the environment of the home. This meant that risks had been assessed and an action plan put in place to tell staff how these were avoided or reduced. Staff now had a fire drill once a month. This meant that they were aware of what to do if the fire alarm sounded. What they could do better:
All residents must have a plan of care that tells staff how to meet their personal, health and social care needs. All of the care plans should be reviewed monthly. This is so that the information in it is current and accurate. The number of care staff on duty must be kept under review. This is in order that the needs of the residents can be met at all times. A full work based fire risk assessment must be completed. This is so that each area of the home is assessed for risk of fire and the right ways of managing this put into place. The means of providing an additional toilet facility on the ground floor should be explored. This is so that residents do not have to wait to use the toilet. The bathroom with toilet on the first floor must not be used as a storage area. This is so that residents can use these facilities if needed. The procedures for obtaining references must be improved. The manager must write to the person who is to be asked for the reference. The references must include one from the last employer. This is so that the recruitment procedures ensure that residents are safeguarded. Following employment all new staff must receive a thorough Induction. All staff must receive a minimum of 3 days paid training each year. This training must cover all aspects of care, health and safety, protection of vulnerable adults, moving and handling and fire procedures. This is in order to ensure that all staff are competent and to protect residents and staff. All care staff should receive regular, formal supervision. This is needed to ensure that they are aware of their roles and responsibilities and the philosophy of the home. The amount of self-auditing must be extended. This would enable the Manager to identify areas that needed attention and to create an action plan to resolve these. The Pharmacy Inspector looked at the control of medications within the home. A separate report has been issued on the ways in which staff at the home can improve their practice.
St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 7 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. St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 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 St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Residents could be confident that the home could meet their needs. This was because they had their needs assessed before moving into the home and received a letter confirming whether the home could meet these needs. EVIDENCE: The files for two residents admitted over the summer months were viewed. These showed that an assessment had been done before the residents came to live at St Hubert’s Lodge. The assessment covered personal and health care needs. It gave sufficient information for the manager to make a decision about whether the prospective resident’s needs could be met at the home. A letter was then sent to the prospective resident telling them whether the home could meet their needs. This documentation was kept on file. Intermediate care was not given at St Hubert’s Lodge. St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, and 9 Not all residents had the new style of care plan. The care plans were not reviewed monthly. This meant that not all their health and personal care needs had been assessed and information on how to meet these was not up to date. EVIDENCE: The files for two residents were viewed. These were both in the new style of documentation. There was written consent from one of these residents that her care could be discussed with her relative. The relative had signed the plan to show that they had been involved in the care planning. This is an example of good practice. One of these plans of care had not been reviewed since it was written in July 2005 and the other had not been reviewed since September 2005. There were only four of the 12 residents who had the new style of care plan. The file for one of the residents who had the old style of documentation was viewed. This showed that the plan of care had not been reviewed since May 2005. For the residents with the new documentation in place their health care needs had been thoroughly assessed. These included: risk of developing pressure sores; nutrition; risk of falls; and moving and handling needs. The directions given to staff on how to meet these needs were only brief. From talking to the
St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 11 residents it was apparent that they had access to health care professionals. They said how they saw their GP when they were not well. Some talked about the fact that they had attended out-patient appointments at local hospitals. One resident said that the District Nurse came every week to dress a wound on her foot. The Pharmacy Inspector looked at the control of medications within the home. A separate report has been issued. The requirements and recommendations from that report need to be read alongside this one. St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 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 the following standard(s): 13 and 14 Residents were able to make choices about their life at the home so that their lifestyle met their preferences. Resident’s social needs were met through links with their family and friends being maintained. EVIDENCE: Residents said that they were able to make decisions about their life. They were not restricted about what time they had to go to bed or get up. The preferred times for this were noted in the plan of care for one resident. They said they could have breakfast in their bedroom if they wished. All of the residents spoken to were very happy with their life at the home and the way that the staff cared for them. The residents said “You can suit yourself when you get up and go to bed. I just ring the bell and someone comes to help me”, “I can go to my room when I want” and “You can suit yourself what you do”. The new care plan documentation recorded if they wished their plans to be accessed by their relatives. This also allowed them to have some control over their lives. There was information in the Service User’s Guide about visiting. This was described as an “open door” policy. Two visitors were spoken to during the inspection. They both said how they were made to feel welcome when they arrived. They said that they thought the staff at the home cared very well for the people living there. One visitor said that her relative had been in four homes in total and St Hubert’s Lodge was “the best of the lot”.
St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents and visitors spoken to were confident that their complaints would be taken seriously and acted upon. The lack of recording systems meant that any concerns may not be formally acknowledged. The written procedures for responding to an allegation of abuse had been updated and gave good directions to staff. The lack of staff training in this subject may potentially result in abusive practices being unrecognised and unreported. EVIDENCE: There was a complaint procedure on display in the hallway. This was also included in the Service User’s Guide. This gave clear directions on who to make a complaint to and that a response would be made within 28 days. The procedure also had the address and telephone number of the Commission. No complaints had been received at the home for several years. There was no designated recording system for any complaints that may be made to the home. No complaints had been made directly to the Commission. All of the residents spoken to were happy with their care at the home. They said that they usually saw the manager on a daily basis and were able to talk to him about any worries or concerns. They said that they had no fears about “speaking out” or “speaking their mind” to him. The procedure for responding to an allegation or suspicion of abuse had been updated. This complied with No Secrets and gave good directions to staff on what they should do and who they should report to. There was also a Whistleblowing procedure. Both of these were on display in the hallway. Not all staff had received training in Protection of Vulnerable Adults.
St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 21 The general layout and the décor of the home was suitable for the residents accommodated and provided comfortable surroundings. Fire safety equipment was maintained and staff were involved in fire drills. A work based fire risk assessment was needed and further training for staff. This is in order to ensure that the home is as safe as possible and that everyone knows what to do if there is a fire. EVIDENCE: The home was warm, clean and tidy on the day of inspection. The bedrooms were nicely decorated and were furnished in a homely fashion. There had been some raining in affecting the ceiling of the dining room. The manager said that this would be repaired in the near future. There is 1 toilet on the ground floor. The residents said that this sometimes resulted in them queuing to use it. The manager said this was only a problem when several residents wanted to go at the same time e.g. before meals. The bathroom on the first floor had items stored in it, such as a television,
St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 15 mattress and wheelchair. This meant that none of the facilities in this room could be used. Fire drills were now being done on a monthly basis. When these were done the manager talked staff and residents through the procedure to ensure that they understood it. Staff spoken to were aware of what to do if there was a fire. A fire training package had been purchased and this was to be done with staff. Part of the package included a question and answer sheet so that the manager could see what they had understood from the training. The risk of fire had been partly covered in the health and safety risk assessment. A full work based fire risk assessment was needed. St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staffing levels need to be kept under review to ensure that they meet the needs of the residents. The recruitment procedures were not thorough and did not ensure the protection of residents at the home. The amount of staff training had been increased, but more was needed. This is to ensure that all staff have the skills and knowledge to undertake their duties. EVIDENCE: There must be two Care Assistants on duty at all times from 8.00 am – 10.00 pm. It was evident from the duty rota that this was being fully met from 6.00 pm – 10.00 pm. The situation during the day was a little less clear. The manager discussed that he is some times the second care assistant on duty. He has a number of management duties to undertake. This means that one Care Assistant may be undertaking all the care duties at any time. As some of the residents were becoming frail and their dependencies rising, this situation must be kept under review. The duty rota showed that 1 care assistant, with an on call system, were on duty at nights. It was evident from records seen that the on-call person arrived at the home within 5 minutes of being called. The files for two members of staff were seen. These showed that POVA First checks and CRBs were obtained before the person started work at the home. One person had started work without their application form being on file. This person had also brought in their own references. This meant that the manager could not be assured that they were from the person stated. The other person’s file showed that there were two references but one was not from the last employer. Certificates showing qualifications and training were in the staff
St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 17 files. Six members of staff had signed to say that they had received a copy of the GSCC Code of Conduct and practice. Contracts were issued to staff after the probationary period. One contract seen did not reflect the employee’s current job role and hours of work. Evidence of qualifications and training were seen in the files of the staff. There was no evidence that the new employee had done a first day Induction to the home. This is important as it shows what information has been given to the new employee to enable them to understand health and safety issues. Some staff training had taken place since the last inspection. This included moving and handling and NVQ level 2. The records showed that not all staff had carried out the statutory training needed and had not received three days paid training within 12 months. 50 of the care staff had obtained NVQ level 2 or 3 in care. St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 The residents’ finances were well managed ensuring that these were safeguarded. The manager had the necessary experience to manage the home. The internal auditing systems could be improved upon to ensure that the home is run in the best interests of the residents and that the quality of care is appropriate for them. Staff were not being appropriately supervised with the potential that they might not fully understand their roles and responsibilities. All staff had not yet received training in mandatory subjects. This meant that the health, safety and welfare of residents and staff might not be fully promoted and protected. EVIDENCE: The home was managed by one of the registered persons. He had 20 years experience of running a residential home. He was also enrolled on the NVQ level 4 in Care so that he could gain a qualification to show his management knowledge and skills. He had a job description detailing his role and responsibilities.
St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 19 There was no formal measure of the quality of care in the home. Due to the size of the home, the daily involvement of the owner and the small staff team, informal discussions about the satisfaction of the residents took place daily. The residents spoke highly of the daily contact they had with the manager and felt he listened to them and acted on their comments. A residents survey had been started but not completed. There were no residents meetings or staff meetings held. Staff were not receiving regular supervision from senior management. This meant that there were no formal ways of getting people’s views on how the home was being run. Residents were able to look after their own financial affairs if they wanted to and were able. Otherwise relatives usually took on this responsibility. The manager collected the Pension Benefits for one resident. There were records to show the amounts collected, retained and given for personal allowance. A small amount of cash was kept on the premises for two residents. This was kept in a safe. There were records to show amounts deposited, withdrawn and the balance. These amounts were checked and found to be correct. Receipts would be given for any money or valuables left with the staff. An external contractor had checked the Fire alarm and emergency lighting in September 2005. Fire drills were done monthly. Water temperatures were last tested in October 2005. There had been a gap of seven months prior to this. There was a current electrical installation certificate. The Portable Appliance Testing was due. The servicing of the gas boilers and appliances had been done. The lift had been services in November 2005. The bath hoist should have been serviced in June 2005. There were very thorough risk assessments for the premises. One of these related to the kitchen and stated that visitors should not use the kitchen as a thoroughfare through the home. This occurred during the day of the inspection. All staff had received moving and handling training in June 2005. Not all staff had received appropriate training in: health and safety; fire safety; basic food hygiene; first aid; infection control; and Protection of Vulnerable Adults. St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X X X X X STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 21 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. 2. Standard OP7 OP9 Regulation 15(2)(b) 13(2) Requirement The plans of care must be kept under review. All persons administering medication must receive appropriate training. Previous timescale of 31 January 2005 not met. All medication administered must be signed for on a medication administration record. Previous timescale of 31 January 2005 not met. Hand written entries on the medication administration sheets must be signed and witnessed, dated and cross referenced. Previous timescale of 31 January 2005 not met. All residents who self-administer medication must have a risk assessment completed. All staff must receive training in Protection of Vulnerable Adults A work based fire risk assessment must be done. (Previous timescale of 20/05/05 not met.) All staff working at the care home must receive fire safety
DS0000009440.V262122.R01.S.doc Timescale for action 31/01/06 30/06/05 3. OP9 13(2) 30/04/05 4. OP9 13(2) 30/04/05 5. 6. 7. OP9 OP18 OP19 13(2) 13(6) 23(4) (c) 30/04/05 28/02/06 31/12/05 8. OP19 23(4)(d) 31/12/05 St Huberts Lodge Version 5.0 Page 22 9. OP21 13(4) (a) 10. 11. 12. OP21 OP27 OP29 23(2)(j) 18(1)(a) Schedule 2 (3) 13. 14. 15. OP30 OP30 OP33 18(1)(c) 18.1 (c) 24 16. 17. OP36 OP38 18(2) 23(2)(c) 18. 19. OP38 OP38 23(2)(c) 18(1)(a) training. (Previous timescale of 20/0505 not met.) All items stored in the first floor bathroom must be removed. (Previous timescale of 20/05/05 not met) There must be sufficient numbers of lavatories to meet the needs of the residents. Sufficient numbers of staff to meet the needs of the residents must be on duty at all times. The manager must seek the references for new members of staff and not allow these to be delivered by the proposed employee. One of the references must be from the previous employer. There must be evidence of the first day Induction training given to staff. All staff must receive three days paid training within each 12month period. A system for reviewing and improving the quality of care must be established and maintained. All care staff working at the home must be appropriately supervised. Portable Appliance Testing was due on 03/11/05. This must be done as soon as possible and annually thereafter. The bath hoist be serviced as required under LOLER regulations. All staff must receive training in:fire safety; infection control; basic food hygiene; and first aid. 30/11/05 31/03/06 22/04/05 19/11/05 19/11/05 31/01/06 28/02/06 31/01/06 19/12/05 19/12/05 31/03/06 St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 23 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. 3. 4. 5. 6. Refer to Standard OP8 OP16 OP19 OP29 OP33 OP38 Good Practice Recommendations Whilst the new care plans are being introduced the current ones should be kept up to date and reflect the risks and needs of the resident. There should be a separate recording system for any complaints made to the home. Confirmation should be sent to the Commission that the dining room ceiling has been repaired. All staff should have a contract that reflects their current job role and hours of work. The results of the residents’ survey should be collated and made available for people to read. Staff should ensure that they comply with the details of the risk assessments. In particular, visitors should not use the kitchen as a thoroughfare through the home. St Huberts Lodge DS0000009440.V262122.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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