Inspection on 10/07/08 for Stansfield Hall

This inspection was carried out on 10th July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Stansfield Hall 30/07/09

Stansfield Hall 16/07/07

Stansfield Hall 13/11/06

Stansfield Hall 26/04/06

Stansfield Hall 17/10/05

Stansfield Hall 14/06/05

Stansfield Hall 07/10/04

Stansfield Hall 14/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Stansfield Hall Stansfield Hall Temple Lane Littleborough Lancashire OL15 9QH Lead Inspector Sue Jennings Unannounced Inspection 10th July 2008 01:42 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 Stansfield Hall DS0000052796.V366604.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. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stansfield Hall Address Stansfield Hall Temple Lane Littleborough Lancashire OL15 9QH 01706 370096 F/P 01706 370096 rajan630@hotmail.com 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) Rajanikanth Selvanandan Lynda Anne George Care Home 22 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (21) of places Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 22 service users to include: up to 21 service users in the category of OP (Older People) not falling within any other category; up to 1 named service user in the category of DE (Dementia) under the age of 65 years) 16th July 2007 Date of last inspection Brief Description of the Service: Stansfield Hall is located approximately two miles from the centre of Littleborough. The home provides 14 single and four double bedrooms, all of which were let as singles at the time of the inspection. Access to the home is up two steps, although there is good ramped access to the side of the home via the conservatory. Grab rails are provided at each side of the steps. All accommodation is on ground floor level. For safety reasons there is limited access to gardens. A small patio area is provided and is used by residents in fine weather. Parking for approximately eight cars is provided, with further onstreet parking available as needed. There are a number of shops nearby but they are not easily reached by residents. A regular bus service to Rochdale and Todmorden stops close to the home. The most recent Commission for Social Care Inspection (CSCI) report is available in the entrance area and the Service User Guide advises residents and their relatives of this. At the time of this inspection, weekly fees were £333.58 rising to £450.00, the higher fee being for double rooms let as singles. Additional charges are for hairdressing, chiropody, newspapers, dry cleaning, private telephone line rental/calls, and external activities in the form of a small donation for transport. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that people who use the service experience good quality outcomes. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The visit was unannounced and took place over the course of 6 hours on Thursday 9th July 2008. During the course of the site visit time was spent talking to the manager, 3 residents, visitors and 3 members of staff to find out their views of the home. In addition we received completed survey forms from residents, relatives and staff. We spent time examining records and the residents and staff files. A tour of the building was also made. The requirements from the previous inspection had been addressed and there was evidence that the home was continuing to work hard to develop the service. The fees were £385-00 per week. The home did not charge a ‘top up’ fee. Additional charges were made for hairdressing, trips, newspapers, alcohol, clothing and personal toiletries. What the service does well: What has improved since the last inspection? A manager has been appointed who is registered with the commission to carry out the day-to-day running of the home. Staff supervision has commenced. They have carried out a quality assurance audit. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 6 A fire risk assessment has been carried out. A rota has been developed for ancillary staff. All care plans include the date residents were admitted. Residents admitted for respite care had a care plan in place. 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. The summary of this inspection report can be made available in other formats on request. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has systems in place to make sure that people’s needs are assessed before admission. EVIDENCE: We saw that there is an admissions procedure and that needs assessments are completed prior to anybody moving in. Once an individual comes to live there, a care plan is written based on these assessments. Prospective residents were able to visit the home before making a decision to move in. Where this was not possible families were invited to visit on their behalf. One resident said “I am here whilst my son and daughter-in-law are on holiday I came and looked at the home with my son one Sunday afternoon”. Another said, ““I knew this was where I wanted to come”. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 9 One resident who was on respite stay at the home told us “I visited with my son, they showed me the room I would be staying in and they were all very nice, I have never done anything like this before and they made I easier for me”. The home had a Statement of Purpose and Service User Guide, which gave prospective residents and their families information about the home. The manager visited prospective residents in their own home or in hospital to carry out an assessment before admission. This is done to make sure that people are only admitted on the basis of a full assessment. Residents placed by the local authority had a care manager’s assessment of needs. Stansfield Hall does not provide an intermediate care service. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are met by the home and medication practices safeguard residents. EVIDENCE: We saw that each resident has a care plan which sets out how his or her needs are to be met and that this document is reviewed regularly. We saw a sample of care plans. They included information on nursing assessments, moving and handling risk assessments, care managers assessment, oral care, religious and cultural needs, daily life and social activities, pressure area risk assessments, dietary needs, likes and dislikes and allergies. We spoke to residents and they told us they were happy with their care and that staff respected their dignity. One resident said, “They listen when you Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 11 have anything to say” and “I think it is a very nice place to live”. Another said “staff are usually available if they are not busy” and “the support is very good”. Another said “there is always someone to ask they really are lovely”. We spoke to visitors to the home who told us that they were happy with the care their relative received. One told us “ we have been coming for a number of years so they must be doing something right” Another said “they are very good we have no complaints about the care”. One person said “we have no problems with the care it is second to none the staff are lovely with mum”. One resident told us “it really is a lovely place they look after us very well, I could not want for more they are really caring”. Residents who completed a survey all said that they received the medical support they need. One resident said that this support was “very good”. It was evident that residents and staff had a good relationship. Risk assessments are completed around areas such as falls, pressure areas and nutrition. We saw that these were generally well completed. We saw that district nurses visited the home and a tissue viability nurse is also consulted to advise on good pressure area care. A chiropodist visited the home on a regular basis. We saw that medication was dispensed into a ‘Boots’ blister pack monitored dosage system and was stored correctly. We saw that the receipt and disposal of medication was being recorded and that records were generally kept well. One resident told us “The staff help me when I take my medication”. There was a photograph of residents in the Medication Administration Record sheets to enable staff to recognise residents and minimise the risk of administration errors. Daily notes kept by staff should reflect the care delivered by staff. We saw that some of these were very repetitive and general statements such as ‘fine today” and “care as plan”. The current method of recording does not reflect the good level of care that is being provided to residents by the staff. Notes kept by staff need to contain good information which can then be used to evaluate and review the care being provided. We saw staff interacting with residents and from talking to residents it appears that the privacy and dignity of the residents is promoted. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are provided and residents are able to maintain contact with family and friends. Residents have a choice of varied, well-balanced meals. EVIDENCE: We saw the menus. They were varied and balanced and cater for the varying dietary needs of residents. The dining areas were bright and inviting. There were sufficient cutlery and condiments available for service users to use. The lunchtime meal served on the day of the site visit was jacket potatoes with cheese, tuna or baked beans with sponge and custard for sweet. Tea was potato pie with vegetables. One resident told us “I never leave anything the food is lovely”. There is an activities organiser and a weekly programme of activities was displayed in the entrance area of the home. Activities include baking, visiting entertainers, craftwork making floral decoration pieces and painting. A number Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 13 of pieces of artwork completed by residents were displayed around the home. An activity plan for July 2008 was displayed and included ‘The Vine Singers’, armchair aerobics and craft sessions. One resident told us “I spend a lot of time in my room it is very nice I have a nice view from the window and a TV so I sit and watch TV in the afternoons” and “they are all very kind to me if I want anything it is no trouble to them”. Residents told us they were able to participate “as they choose” in any activities. They told us that staff respected any decision in relation to participation of activities. We saw five residents sitting in the sun lounge watching TV or reading. We saw minutes of residents meetings. These covered areas such as menus and activities. It was recommended that an action plan be produced to show that issues raised at these meetings are taken seriously and being acted upon. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place to safeguard residents from abuse and people are confident that their complaints will be acted upon. EVIDENCE: There are suitable procedures in place for dealing with complaints. The complaints policy and procedure is part of the guide for the people living there. The service user guide has a copy of the complaint procedure and each resident is given a copy of this. One resident told us “I have nothing to complain about they are very good” another told us “I would speak to the manager or a senior” and “I was given a complaint procedure”. A relative or friend told us in a survey form “Not been necessary to complain” and “there does not appear to be any discrimination to my knowledge”. Another told us “the home encourages visiting and also taking out”. There was a policy and procedure in place for responding to allegations of abuse. They had a copy of the local adult protection procedures. Staff had attended training in the Protection of Vulnerable Adults (POVA). Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 15 Staff files contained evidence of Criminal Record Bureau (CRB) checks showing that they were safe to work with Vulnerable People. There is an ongoing staff training programme that includes safeguarding adults. We asked staff what they would do if they witnessed an abusive situation and they told us that they would “immediately report it to the manager but if it was the manager they would report to the owner otherwise they would contact the commission for advice”. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are safe and the home’s environment, including the standard of hygiene, was well maintained both internally and externally. EVIDENCE: We saw a sample of residents’ bedrooms and saw that residents had brought some personal belongings with them. All rooms seen were found to be clean and tidy and nicely decorated and those residents spoken to said that they were very happy with their rooms. They told us that bedrooms were being decorated and new carpets fitted as they become empty. Residents were seen relaxing after lunch in the small lounges either reading or watching television. There are small kitchens on each floor so that residents and or their visitors can make a drink. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 17 There was enough housekeeping staff to keep the home clean and we noted that there were no unpleasant odours during the tour of the home. We saw that toilets had paper towels and liquid soap and there were sufficient supplies of protective gloves and aprons available to staff. There were also sanitising gels in all areas of the home. All of these help to minimise the risks of infection. There were two lounge dining rooms. These had been refurbished since the last inspection. This included new dining tables and chairs, new armchairs and new carpets. These rooms were warm, bright and airy with a relaxed comfortable atmosphere. Dining tables were nicely set with flowers, matching tablecloths and napkins. They told us that there are plans to replace the carpets along the ground floor corridors. The internal seals on a number of the double glazed bedroom window units appear to have failed and this gave the appearance of the inside of the windows being steamed up. This obscured a clear view from the windows for residents and it is strongly recommended that these be repaired or replaced. A number of bedrooms are designated smoking rooms. Cigarette smoke was detected in the adjoining corridors. The owner must take advice from the local environmental health officer with regard to the smoke free legislation and how this effects the home. Extractor fans should be fitted in bedrooms where residents smoke to minimise the effects of cigarette smoke in the adjoining corridors. One visitor told us “they have been doing the place up recentl. It was a bit the worse for wear it is much nicer now he is really trying to improve things”. Aids and adaptations were provided to assist in moving residents safely. These include manual hoists and assisted bathing facilities including a parker bath and a walk-in shower. There was evidence to show that staff had received manual handling training to enable them to use the equipment safely and safeguard residents. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are adequate numbers of staff on duty with the skills and knowledge to meet residents’ needs and the recruitment procedures protect residents. EVIDENCE: A sample of staff files was examined these were well maintained and contained all the necessary checks including Criminal Records Bureau (CRB) and checks against the Protection of Vulnerable Adults list (POVA). Recruitment procedures could be further improved by making sure that copies of documents provided as proof of identity are signed and dated to show that the originals have been seen. Staffing rotas showed that there were enough staff to meet resident’s needs. Staff spoken to said that they had access to training. A training plan was seen that showed training in relation to manual handling, medication, fire safety, first Aid, and Protection of Vulnerable Adults had been provided. The manager reported that regular staff supervision was provided and all staff completed an induction period. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 19 There was evidence on staff files to show that staff were given a copy of their job description detailing their roles and responsibilities. Staff files provided evidence of vocational training in service related areas, e.g. moving and handling, food hygiene, safe administration of medicines and fire safety. Training needs were identified during supervision and the home provided ongoing refresher training. Staff have the opportunity to complete the NVQ in care and currently more than half the care staff hold the NVQ2 in care. Staff were caring and approached residents in a polite and respectful manner. Residents told us that staff were “ kind and caring”, “very helpful” and “quite friendly”. Staff told us in survey forms “have worked there only a short time and due to the demand on all the staff I have not had time to look at a care plan”. Another told us “I have not yet started my training but am down for 3 different courses”. A relative or friend told us in a survey form “training sessions are continued internally”. Another told us “mum’s general health has greatly improved since admission to Stansfield Hall” and “I have an excellent relationship with staff”. One relative or friend told us “they are lovely” and “staff are friendly and caring”. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is safe, well managed and run in their best interests. EVIDENCE: The manager has considerable knowledge and experience of running a care service for older people. They had a good understanding of the conditions and illnesses that are associated with old age and was able to address such issues quickly, benefiting the residents. The manager has showed a good understanding of the areas of weakness and there is a good capacity for the service to improve. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 21 One relative or friend told us “the owner and manager of Stansfield Hall are very involved and visible around the home”. Comments from staff about the management of the home included “the manager is very good and is quick to set in force any change which she thinks is needed”. Another said, “Always asks if I am OK and explains very clearly when I ask questions”. We saw that a fire risk assessment had been completed since the last inspection. The fire risk assessment should take into account the implications of residents smoking in their bedrooms. One resident whose bedroom is on the same corridor as the designated smoking rooms prefers to have their bedroom door open. During the site visit we saw that this door was held open with a wooden wedge. Where residents prefer to have their doors open automatic door closure systems linked to the fire alarm system should be fitted to the bedroom doors and this taken into account in the fire risk assessment. A quality assurance system has been introduced. People living at the home and their relatives or representatives were sent questionnaires as part of the quality assurance process. They told us that a survey was underway and we saw several completed surveys. The results of this survey will be used to improve the service. They told us that the home’s policies and procedures were regularly updated. The manager was aware of the Mental Capacity Act 2005 and its implications in relation to helping residents to make decisions that affect their lives. It is recommended that the home’s policies, procedures and working practices be reviewed to reflect the implications of the Mental Capacity Act 2005. This is particularly important in relation to handling resident’s money. It is recommended that the home develop a formal agreement between residents or their representatives, that staff can access people’s personal monies to purchase personal items. It is also recommended that a copy of the Codes of Practice for the Mental Capacity Act be kept in the office for staff to reference. It provides guidance and information for anyone who works with or cares for people who may lack capacity to make decisions. Health and Safety checks take place to make sure people are kept safe and good records are kept of these. Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 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 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 13 (4) Requirement The owner must take advice from the local environmental health officer with regard to the smoke free legislation and how this affects the home. Timescale for action 15/08/08 2. OP38 13 (4) The owner must take advice 15/08/08 from the local fire officer with regard to fitting an automatic door closure system on the doors of residents who wish their doors to be held open. The fire risk assessment must take into account the risks to residents in designated smoking rooms. 15/08/08 3. OP38 13 (4) Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 24 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 OP14 Good Practice Recommendations It was recommended that an action plan be produced to show that issues raised at these meetings are taken seriously and being acted upon. It is recommended that references be either followed up with a telephone call, requested on letter headed paper or contain a company stamp to show that they are genuine. It is recommended that all photocopied documents are signed to indicate that the original had been seen. It is recommended that the home develop a formal agreement between residents or their representatives, that staff can access people’s personal monies to purchase personal items. Policies and procedures should be reviewed to take into account the implications of the Mental Capacity Act 2005. 2. OP29 3. 4. OP29 OP35 5. OP38 Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Stansfield Hall DS0000052796.V366604.R01.S.doc Version 5.2 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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