Inspection on 16/05/07 for Steep House Nursing Home

This inspection was carried out on 16th May 2007.

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

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

Other inspections for this house

Steep House Nursing Home 28/05/08

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Steep House Nursing Home Tilmore Road Petersfield Hampshire GU32 2HS Lead Inspector Anita Tengnah Unannounced Inspection 10:00 16th May 2007 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 Steep House Nursing Home DS0000068710.V336146.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. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Steep House Nursing Home Address Tilmore Road Petersfield Hampshire GU32 2HS 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) 01730 260095 01730 231148 London Residential Healthcare Ltd Post Vacant Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46), Physical disability (46), Physical disability of places over 65 years of age (46) Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: Steep House is a care home with nursing providing care and accommodation for 46 service users. The home has thirty-seven single rooms, four shared rooms and three communal rooms that are accommodated over three floors. There is a passenger lift that allows access to all floors. The home has large surrounding grounds with patio areas around the homes that are accessible to the services users. LRH homes own the service with three other homes in the area. The home is situated in a rural area near Petersfield within reach of some local amenities. The current fee charged is £450-£650 Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection of this service that changed hands in December 2006. The unannounced visit was undertaken on the 16th of May 2007. The process included a tour of the service where a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. As part of case tracking 6 staff and 11 service users views were sought and care records were looked at. Information gained from the Annual Quality Assurance Assessment was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. Positive comments were received from the service users regarding the care that they were receiving at the home. The commission received 4 comment cards from the service users and a relative was spoken with at the time of the visit. Care practices observed at the time of the visit showed that the staff and the service users had developed good relationships and care was provided in a respectful manner. What the service does well: What has improved since the last inspection? This is the first inspection since the new owner took over the service. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Steep House Nursing Home DS0000068710.V336146.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 Steep House Nursing Home DS0000068710.V336146.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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission assessment process is good and ensures that service users’ needs are assessed and the home can meet them. The home does not provide intermediate care. EVIDENCE: The care records of two recently admitted service users were looked at as part of case tracking. Detailed pre admission assessments of needs were carried out and staff reported that this information is used to formulate their initial care plans on admission. A service user’s record who was admitted from the hospital contained discharge information that staff said was very useful. Assessment of needs included dietary needs, manual handling assessments, skin integrity and fall history. The evidence that the service users/relatives are Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 9 involved in the assessment process should be further developed as appropriate in order to ensure that all care needs are identified. This was not available in records seen. Comments received indicated that the home offers the service users a choice of visiting the home prior to admission. A service user spoken with reported that his son visited. The home provides short respite care to service users. The home does not provide intermediate care. Steep House Nursing Home DS0000068710.V336146.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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans and records of care given were available. Further developments of night care plans and pen pictures would benefit the service users. The health care needs and access to external agencies was satisfactory. The medication management was satisfactory. The management of prescribed ointments need reviewing in order to meet with practice guidance. The service users are treated with respect and their right to privacy maintained. EVIDENCE: Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 11 The care records of 4 service users were looked at as part of case tracking. These contained details of assessments such as manual handling, dietary needs, continence, medication, and diabetes. Daily records were maintained of the care given. Care plans included personal care, continence, manual handling instructions and skin care. A service user identified as a diabetic had care plan relating to a diabetic diet. Care plans included night care, however these lacked details such as the preferred times that people chose to wake up and go to bed in order to promote the service users’ autonomy and choices. One service user said that he liked to go to bed fairly early and watched television in bed and staff helped him as required. Two service users said that they went to bed whenever the staff “are ready” as the “girls have a job to do”. Another service user said that she was woken up early and got up. This was brought to the attention of the manager and care plans would be reviewed to contain details/ service users’ preferences. The care plans were reviewed regularly to reflect any changes in the needs of the service users. The manager reported that all the service users are registered with the local surgery. The GP undertook a weekly visit to the home and was available at other times as required. The GP saw all the service users on a monthly basis and all the service users are seen on a monthly basis. Advice was sought as required from external healthcare professionals. Pressure relieving equipments were available for the prevention and treatment of pressure ulcers. The manager reported that there was no service user with pressure ulcer at the time of the visit. One service user was receiving treatment from the hospital for leg ulcers. The home had policies and procedures for the management of medication. All medications were stored securely including those that should be kept in the fridge and controlled drugs. Staff reported that the registered nurses were responsible for the administration of medication and that regular updates in medication was available. A sample of the Medication Administration Record (MAR) sheets seen indicated that all oral medication administered was recorded accurately. It was noted that creams/ ointments found in a shared room did not contain the name of the service users and these were not stored separately. These posed risks that the service users may receive the wrong cream and an infection control risk. A review is needed and the ointments must be labelled with the service users’ names to ensure that they are only administered to the named service user as prescribed. There was no record kept of creams/ointments and when these are administered to the service users. The commission received 4 comment cards and the service users spoken with indicated that they were satisfied with the care that they were receiving. Comments included “the care service gives an all round service according to my father’s needs”. Service users said that “the carers are very good” and that they are well looked after. Comments were that staff treated them with Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 12 respect and “the staff are very kind”. Staff were observed knocking prior to entering the service users’ bedrooms. Steep House Nursing Home DS0000068710.V336146.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. This judgement has been made using available evidence including a visit to this service. The social and recreational facilities for the service users are inadequate and need further development to meet all the care needs of the service users. The service users are well supported to maintain links with their family and friends. The service users are treated with respect. The meals are good and well managed, meeting with the satisfaction of the service users. EVIDENCE: Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 14 The home has some activities for the service users and information received indicated that these included music and movement, games, quizzes, and reminiscence. The carers provided these activities, as the home did not have an activity coordinator. Staff and the service users spoken with reported that the activities could be improved, as at present activities these are dependent on the carers’ availability. The manager reported that some of the planned activities for the summer included a visiting animal farm, cream teas, visit to garden centre and the local pub. The manager discussed the plan for a sensory garden and employing an activity coordinator on a permanent basis and increasing activity equipment. Two service users who preferred to spend time in their rooms commented that it would be nice for staff to have time to chat to. Two service users said, “there is not much happening in the day”. The home has a number of service users with dementia and the manager was aware of further development of their life history/ pen pictures in order to be able to provide suitable activities to meet their needs. The manager stated that two people went out to the “welcome club” weekly. The manager was also looking into access to a visiting library for the service users. The responsible individual talked about bringing books from the sister home for the service users in the meantime while the visiting library facility was being explored. The home has an open visiting policy and the record of visitors to the service as maintained at the home supported this. A relative spoken with said that he visited at all times and “was always made welcome”. Three service users confirmed that they could see their relatives in private. Comments included “this is a nice place to live”. All of them spoken with said that they felt safe and the staff treated them with respect. Interaction observed at the time of the visit showed that the staff have developed good relationships with the service users. Information from the AQAA indicated that all the service users were from a Christian denomination. The manager stated that the home had a visiting clergy and undertook a service in the lounge for some of the service users. The priest also came and saw the service users on an individual basis as requested. The home has a planned menu that is rotated on a regular basis. Comment cards received and the service users spoken with said that the meals were “very good and hot and cold drinks were available” at all times. Comments included “excellent food” and “good choice “. This also included cooked breakfast as requested. Three service users were observed finishing breakfast at around 10 o’clock in the dining room and the chef said that meal times were flexible to the needs of the service users. Another service user commented that there was “good choice and can ask for different food if you don’t like what’s on the menu”. The chef went round to see the service users and discussed with them the menu for the day. A service user said that he was looking forward to the salmon fish cakes for lunch. The lunchtime meal was observed and the food was well presented and appeared appetising and well balanced. Staff were Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 15 available to offer support with meals as needed and the meal was not rushed. The chef had introduced a small aperitif at lunchtime such as wine or sherry that a number of the service users were partaking in on the day of the visit. Some of the service users spoken with said that they enjoyed this. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users are confident in raising concerns with the staff. Staff have good knowledge of the prevention of abuse. The reporting process needs reviewing so that action is taken promptly. EVIDENCE: The home has a procedure in place on how to deal with complaints. The service users said that they would speak to the staff if they “had any worries”. The home has a compliment folder. The manager said that there had been no complaint since she had joined the service. There was no complaint log for the recording of concerns raised and any action taken. The responsible individual confirmed that a log would be put in place including the relevant forms for the staff to record in. The service users and a relative spoken with had positive comments about the service. Comments included “we have nothing to grumble about”. The home has the Hampshire adult protection procedure and the manager reported that training in the prevention of abuse was available. Staff are issued with the whistle blowing procedure on employment. Staff spoken with were aware of what constituted abuse and said that they would report to the manager. Discussion with senior staff indicated that they would not report to the external authority in her absence and would wait for the manager to do Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 17 this. This was discussed with the responsible individual and the manager as there may be delays in reporting any allegation of abuse. The manager said that this would be looked into. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and comfortable. The infection control procedures were satisfactory. EVIDENCE: A tour if the service was undertaken as part of the visit and a high proportion of the service users bedrooms were seen. The call bell system has been reviewed and there were call bells available to both the service users in the shared rooms seen. Eight of the service users spoken with said that they liked their rooms and comments included ” I have everything I need and it is good”. It was evident that the service users are supported to personalise their rooms and bring in items of personal belongings. A service user talked about his computer that he uses all the time that had been bought by his son and he Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 19 uses this to write letters. All the rooms were naturally ventilated and there was no offensive odour detected at the time. Other comments were that the inside décor was looking tired and would benefit from redecoration. Some of the bedroom locks were out of order and this was brought to the attention of the manager and must be repaired. It was noted that the majority of chairs in the communal areas were low. One of the service users said that he had difficulty getting out of the chairs as they are very low and he is quite tall. This was rectified at the time of the visit. The manager should undertake a review of seating facilities in the communal areas and take appropriate actions in order that the service users are supported to maintain their independence. The bath panel on the second floor was in poor state of repair with paint peeling. This must be addressed as it poses an infection control risk, and it cannot be cleaned adequately. Information and training on infection control was available to staff. Practices observed on the day indicated that the staff were aware of this. Equipment such as gloves and aprons were available to prevent the spread of infection. This included different coloured aprons for serving meals. The home has a laundry situated in the basement. This was found to be in a poor state of repair with limited space with no natural ventilation. The laundry was fitted with two washing machines and a dryer. Staff reported that the provider was planning a refurbishment of the laundry as part of his extension of the service. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has adequate staff to meet the present needs of the service users. The staff development programme is satisfactory. The recruitment process is poor and inadequate and put the service users at risk. The training programme is satisfactory. EVIDENCE: The home has a rota for care staff and a separate one for ancillary workers. The rota seen indicated that there are two nurses on between 8 am and 8pm with 6 care staff in the morning and 5 in the afternoon, at night there is one nurse and 3 care staff, they are supported by domestic and catering staff. The staff and the service users said that they felt that the staffing was adequate to meet their needs. Service users said that “usually” they did not have to wait long when requiring help. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 21 Information received indicated through the AQAA indicated that there are 10 staff who have completed the NVQ level 2 or above and 7 staff were working towards this level. The home also has staff from overseas who are supported to undertake the supervised practice course. Two of the staff spoken with at the time of the visit confirmed that one of them was awaiting her result and the other one was due to start the course soon. The nurses undertook regular updates/ training in order to maintain their registration. A sample of 4 staff records was seen as part of the visit. All applicants completed an application form. The manager said that she interviewed all the candidates. The staff records indicated that three staff had been employed prior to Criminal Record Bureau (CRB) and POVA first clearance checks had been received. Two of these had now their CRB in place, however one of the staff has no CRB or POVA first clearance check available. This was brought to the attention of the manager and urgent action is required. The manager reported that there is a training programme in place for the staff and this was being further developed. The AQAA indicated that 4 staff are due to start nutrition and hygiene via a distant learning course. It was difficult to ascertain during the visit the number of staff who had completed mandatory training in health and safety including fire safety. This was discussed with the manager and the development of a training matrix would be beneficial in capturing this information. This would further aid in identifying any gaps in training that would need to be addressed. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has the day-to day- responsibility of the service. The auditing of the service users’ views is good. The home does not manage the service users’ finances. There is a lack of supervision of staff’s practices within the home. The health and safety of the service users are not fully protected. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager is a registered nurse who had been at the home since October 2006. She has applied to be registered with the commission and she has completed her Registered Manager’s Award (RMA). Discussion with staff indicated that there is a staff team that works well together. Staff said that they enjoyed working at the home and they had a stable workforce at present. They have developed good relationships with each other and the service users. The manager reported that an audit of the service users views was planned in the coming months, as this is a new service. The responsible individual discussed that the provider had introduced newsletters and carers support meetings as part of improving communication with people who use the service. There are also regular staff meetings to keep them updated on the plans/changes within the service. The manager confirmed that the home did not manage any of the service users’ money and the administrator sent invoices to their representatives for all financial transactions. Discussion with staff showed that there is no structured supervision programme in the home in order to monitor their practices. This was brought to the attention of the manager who confirmed that this would need to be addressed. A supervision programme must be developed and all care staff must have supervision at least 6 times a year as part of their practice. Information received and a sample of the servicing records seen showed that there is an ongoing programme in place to ensure that equipments are maintained in safe conditions. The record of the weekly fire testing showed that this had not been completed since the 23rd of April 07. The last fire training record was in September 2006 where 12 staff completed this training. There was no record of fire training for the new staff in the records seen. A random check of hot water temperature in the communal bathroom showed that the bath and sink hot water was being delivered at 54 and 53 degrees centigrade. This was brought to the attention of the manager as they pose risk to the service users’ safety and welfare. The responsible person discussed that the home would be looking into fitting all the sinks with thermostatic control valves in order to reduce the risk to the service users. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 24 On a tour of the building it was noted that the cleaning trolley was left unattended in the corridor for a long period of time and contained a number of solutions that are hazardous to health. This was brought to the attention of the manager, as urgent action was required. The manager must ensure that all substances that are hazardous to health (COSHH) must be kept safely at all times. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 25 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 1 X 2 Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 OP9 Regulation 17(1) (a) Requirement All prescribed creams / ointments must have the service users’ names on them. A system to record the administration of prescribed creams must be implemented. An activity programme must be further developed, ensuring that it meets the needs of all the service users. There must be a robust recruitment process in place and all necessary staff checks must be completed prior to their employment. Staff may not work at the home until POVA clearance is gained. A supervision programme must be developed. All care staff must receive supervision at least 6 times a year as part of their practice. The staff must have suitable training in fire prevention and regular fire drills. The fire alarm must be tested at regular intervals as required by the fire safety legislation. DS0000068710.V336146.R01.S.doc Timescale for action 30/06/07 2 OP12 16(2) (m) 30/06/07 3 OP29 19(1) 30/06/07 4 OP36 18(2) 30/06/07 5 OP38 23(4) (c ) 30/06/07 Steep House Nursing Home Version 5.2 Page 27 6 OP38 12(1) 7 OP38 13(4) (a) (c ) All substances that are hazardous to health must be kept locked and maintained safely at all times. The hot water must be delivered at the correct temperature to avoid the risk of scalding to the service users. 15/06/07 30/06/07 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 OP30 Good Practice Recommendations A training matrix should be put in place to record and identify any gaps in staff training. Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Steep House Nursing Home DS0000068710.V336146.R01.S.doc Version 5.2 Page 29 - 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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