Inspection on 18/05/06 for Stoneleigh House

This inspection was carried out on 18th May 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stoneleigh House 17/06/09

Stoneleigh House 23/01/08

Stoneleigh House 03/09/07

Stoneleigh House 28/07/07

Stoneleigh House 13/10/05

Stoneleigh House 09/06/05

Stoneleigh House 24/11/04

Stoneleigh House 06/04/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stoneleigh House Cooper Street Springhead Oldham OL4 4QS Lead Inspector Steve Chick Unannounced Inspection 18th May 2006 09:30 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 Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 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. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stoneleigh House Address Cooper Street Springhead Oldham OL4 4QS 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) 01616245983 0161 678 2158 Masterpalm Properties Limited Care Home 31 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (23) of places Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user to include up to 23 OP up to 8 DE (E) Date of last inspection 13th October 2005 Brief Description of the Service: Stoneleigh House is a detached property in a semi-rural location. It is situated close to public transport and local amenities. To access the property service users have to manage a small incline from the main road. The outside of the property is well maintained with landscaped gardens and views over the local area. Accommodation is provided in 27 single rooms, of which 26 have an ensuite facility. Of the twenty six rooms two share an adjoining ensuite. There are two shared rooms, both of which have ensuite. Communal facilities include three large lounges one of which is an allocated smoking area and a large dining room. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection three service users were interviewed, as were two relatives of service users. Additionally discussions took place with the manager and deputy manager and the owner. The inspectors also undertook a tour of the building and scrutinised a selection of service user and staff records as well as other documentation, including staff rotas, medication records and the complaints log. One meal was sampled. All Key standards were assessed during this unannounced inspection.. What the service does well: What has improved since the last inspection? Since the last inspection, areas of good practice in the home have been maintained. There was evidence of some refurbishment within the home. There was evidence of an improvement in several areas, including service user assessment, staff recruitment and staff induction. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 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. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 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 Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is adequate. Prospective service users are appropriately assessed before moving to the home, to ensure the home can meet their needs. The written information provided in the service user guide and terms and conditions does not give sufficient, objective, information to enable prospective service users to make an informed choice to live in the home. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: The statement of purpose and service user guide were available, but needed to be redrafted to accurately reflect the reality of the services available at Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 9 Stoneleigh, and include all the areas required by Schedule 1 of Care Homes Regulations 2001 (these omissions were relatively minor). The manager reported that she was in the process of redrafting the statement of purpose and service user guide. A random selection of service users’ files was scrutinised. All had a copy of an assessment undertaken by an appropriate community based professional. The manager reported that Stoneleigh complemented the assessment with one of their own and would not agree to admit anyone whose needs the home could not meet. There was no documentary evidence the service users were given written confirmation that Stoneleigh could meet their needs. Each service users’ file seen, had a copy of a contract between the ‘placing Local Authority’ and Stoneleigh, but not the service user and Stoneleigh. The level of fees is addressed in the service user guide, as is a minimal statement of the terms and conditions. Stoneleigh does not offer intermediate care. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 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, 9 and 10. Quality in this outcome area is adequate. Appropriate links are maintained with health care professionals to ensure service users’ health care needs are met. Inconsistent documentation of the care offered and reviews of care needs has the potential to leave service users with unmet needs. Written medication procedures do not offer a robust framework to protect the interests of service users. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: A random selection of service users’ files was seen. All had a copy of a written plan of care. There was documentary evidence that these were periodically reviewed, but not all, consistently, on a monthly basis. The manager reported Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 11 that the format of the written care plans was being changed. Examples of both ‘old’ and ‘new’ formats were seen and the new ones indicated a significant improvement in areas addressed, and detail. A range of recording and monitoring tools were seen on files. As with several other areas of documentation these presented as being used inconsistently, with the result that the information they contained could not be relied upon to be accurate. Sit on scales were available to ensure weight could be monitored for all service users. Again the records of weight gain and loss was maintained intermittently. The manager reported that she was aware of the shortcomings in the recording practices in the home and that she was beginning a strategy to address these issues. She also reported that she had prioritised the need to address actual care practice, which she now felt was much improved. Service users spoken to during the inspection were positive about the way in which their needs were met at Stoneleigh. There was documentary evidence of service users having access to the full range of medical and paramedical services. This was confirmed by service users spoken to and a relative who was spoken to. One set of ‘daily records’ seen, gave a clear picture of observations and interventions before a service user was appropriately admitted to hospital. Stoneleigh used a pre dispensed monitored dosage system to administer service users’ medication. Medication administration records presented as being appropriately maintained by the home. However, some had inappropriate advice from the pharmacy, such as “ follow printed instructions”, when there were no printed instructions. While this is primarily a responsibility of the pharmacy, to provide the instructions, the procedure for checking the medication into the home should have identified this gap. Controlled drugs were appropriately stored and recorded. Medication was appropriately stored in a locked room, but the room itself was untidy and would benefit from more regular housekeeping. Not all service users had photo identification attached to the medication administration records, thus posing the risk of administering the wrong medication. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 12 It was reported that one service user was administering some of their medication themselves. A written risk assessment had been undertaken, but was in insufficient detail to demonstrate that all predictable areas of risk had been addressed. Discussion with the deputy manager indicated that this was an administrative oversight. The written medication procedures did not fully reflect best practice. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Service users benefit from an appropriate range of social activities both within the home, and outside the home. The home maintains a friendly atmosphere which enables visitors to feel comfortable to visit and maintained contact with friends and relatives. The provision of food is good and menus are designed to reflect the wishes of the service users. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: One meal was sampled during the inspection. This was pleasantly presented and tasty. Service users and one relative were complimentary about the provision of food. The relative who expressed a view, cited the meals as one of the best things about Stoneleigh. Service users confirmed the availability of alternatives to the main menu. Appropriate food stocks were on the premises Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 14 and the manager reported that she was able to use her discretion regarding the food ‘budget’. A range of social activities are provided, including trips out and visiting entertainers. Service users were able to confirm their attendance on outings and expressed satisfaction with social life in the home. One service user was complimentary about the fact that staff often join in with the outings even when off duty. An activities coordinator maintains an appropriate record of individual’s involvement in activities. The manager reported that some social activities are undertaken jointly with other homes in the area which are owned by the same company. The manager reported that there were no unreasonable restrictions on visitors. This was confirmed by visitors spoken to during the inspection, one of whom commented on the “very friendly” staff. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. The home maintains an appropriate ethos of responding to complaints which helps to maintain a safe environment for service users. Effective procedures and staff awareness assist in ensuring that service users are appropriately protected from abuse or exploitation. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: Stoneleigh has an appropriate complaints procedure. The home maintained a complaints file which included information about complaints received. This system would be improved by the inclusion of a summary of information including the nature and date of the complaint, action taken, and response to the complainant. Staff who were interviewed during the inspection demonstrated an appropriate understanding of the complaints and ‘whistle blowing’ procedures. Service users who were spoken to expressed the view that any complaints they may express would be taken seriously by the staff and management team. Similarly they said they felt safe at the home and had neither experienced nor observed any harsh or inappropriate behaviour from any staff. This view was Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 16 endorsed by one relative who had had contact with the home for several years. The other relative did not have a view at the time of the inspection as they had had a very short experience at the home. The home had copies of the Local Authority protection of vulnerable adults procedures as well as their own. In a recent allegation relating to the theft of money from the home, appropriate POVA procedures had been followed. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. Quality in this outcome area is good. Stoneleigh provides accommodation which is kept clean, tidy, odour free and service users are enabled to personalise their own rooms. This enables service users to live in comfortable surroundings. Some failures in the routine maintenance of the building detract from the homely atmosphere and could put service users at risk. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: A tour of the building was undertaken which included a selection of service users’ bedrooms, which service users could lock if they wished. Bedrooms demonstrated an appropriate range of personalisation, reflecting the tastes of the occupant. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 18 Overall the building was clean and odour free. This was confirmed as the usual condition of the home by service users and visitors spoken with. Service users also confirmed the availability of clean bed linen. An appropriate range of bathing and toilet facilities were present. A range of aids and adaptations were available to assist service users with restricted mobility. There was evidence of maintenance and refurbishment having been undertaken since the last inspection. However several issues were identified at this inspection which needed further work. These included some bedrooms in need of redecoration, some failed double glazing units and worn carpet which could pose a tripping hazard. The manager reported that these issues had already been noted and action was planned for the remedial work to be undertaken. She also reported that the program of work which was being undertaken had been prioritised on the basis of greatest need. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29, 30. Quality in this outcome area is adequate. Recruitment procedures are followed with insufficient rigor to maximise the possibility of identifying, in a timely manner, potentially inappropriate staff. This could pose a risk to service users. Stoneleigh provides appropriate numbers of appropriately trained staff to ensure the care needs of service users can be effectively met. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: A selection of staff files was scrutinised in connection with recruitment and vetting practices. There was documentary evidence of two written references, POVAfirst and a CRB (criminal record bureau) declaration having been obtained. However in two cases the second written reference was not received until after the person had commenced work. Declarations of the applicant’s employment history was not always given in sufficient detail to identify all potential gaps. In one example there was no recorded explanation for a gap in the employment history of five months. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 20 A copy of the staff rota for the week in which the inspection took place was scrutinised. This demonstrated that appropriate staff numbers were supplied to effectively maintain an appropriate service. A range of training opportunities was available for staff. There was documentary evidence that gaps in individual’s training needs were identified and arrangements made to provide access to appropriate courses. Staff who were interviewed reported that they had appropriate training to effectively undertake their tasks. Service users spoken to were positive about the competence and approach of the staff team. This observation included the staff who worked the night shift. The manager reported that 9 care staff held NVQ II or higher. This represents 43 of the care staff. Additionally nine care staff had been enrolled to undertake the training, which, assuming they are successful, would exceed the National Minimum Standard of 50 . New staff were subject to a period of induction. The record of induction would be improved by the inclusion of the date the work was done and of the assessors input. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. Quality in this outcome area is adequate. The manager has the necessary skills and attributes to maintain and open atmosphere which enables service users to feel comfortable with the relationship between staff and themselves. The Quality Audit and Quality Monitoring systems are insufficiently structured to maximise the ability of service users to influence the running of the home. The health and safety of service users is potentially compromised by a lack of transparency in some of the required procedures. This judgement has been made using available evidence, including a visit to the service. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 22 EVIDENCE: Service users and visitors reported an open atmosphere with effective communication with staff. There was documentary evidence of service user meetings, which indicated that service users were able to express their views. The manager reported that she had approached a relative who may be willing to take over running the meetings, which could serve to further enhance transparency and ensure service users’ views are heard. At the time of this inspection the Commission for Social Care Inspection was processing an application from the manager for registration. Subsequent to the inspection this application was approved. The manger was undertaking the RMA (Registered Mangers Award) which she hoped to complete before the end of 2006. There was good evidence of the manager having consolidated her position in the home. This had led to a positive impact on many areas of the home’s functioning. Discussion with the manager indicated that she was aware of areas of weakness in the running of the home and had strategies to address these issues. Whilst there was clear evidence that the owner was a frequent visitor to the home, there was not documentary evidence of a specific monthly visit and report on the running of the home. There was not a specific Quality Audit and Quality Monitoring system in place which had completed the full cycle resulting in structured consultation with service users and an action plan based on the outcome of that consultation process. The manager reported that she was in the process of developing questionnaires for service users and staff to progress this issue. In the period preceding this inspection, the investigation, by the home, of a complaint relating to missing money held by the home on behalf of a service user had uncovered the theft of a significant amount of service users’ money. Appropriate investigative procedures were followed and the procedure for the safe keeping of service users’ money had been appropriately changed. The home had reimbursed all the money to all service users who had been affected and no service user suffered any disadvantage as a consequence of this incident. A selection of records relating to money held by Stoneleigh on behalf of service users was scrutinised. These presented as being predominantly appropriately maintained, although staff and service users were not always signing the record to confirm individual transactions. The ‘accident’ book was scrutinised. This presented as being appropriately maintained with the exception of some records lacking clarity about whether or not the accident had been witnessed. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 23 Stoneleigh had been visited by the Greater Manchester Fire and Rescue Service before this inspection. Gaps in the fire risk assessment had been identified. The manager reported that a new member of staff with experience of fire procedures had been delegated to address this issue. This staff member was reported as liaising with GMFRS to achieve an effective outcome. The record of fire detection and prevention procedures was scrutinised. This required more detail in connection with checking that the means of escape are clear, that fire extinguishers are accessible and that emergency lighting is checked monthly. There was evidence of periodic fire drills. An unplanned drill occurred during the inspection and staff were observed to respond appropriately. Evidence was seen of a maintenance contract regarding the lift. There was no documentary evidence available to indicate if work identified as necessary had been done, or if the lift had been independently inspected. Health and safety procedures relating to food hygiene and the use of cleaning materials presented as being appropriately maintained. Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 24 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 2 Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 and 5 Requirement Timescale for action 15/07/06 2 OP2 5 3 OP7 15 4 OP9 13 The registered person must ensure residents and their representatives are provided with accurate information on the facilities and services and any reason for any additional charges. (Timescale of 31/12/05 not met) The registered person must 15/07/06 ensure that all service users are provided with the home’s terms and conditions. The registered person must 01/08/06 ensure that care plans are in sufficient detail to fully identify the care necessary for each individual, and to detail the way in which their care needs are to be met. The registered person must 15/07/06 ensure that the medication procedure is redrafted to give appropriate guidance in respect of all aspects of the receipt, storage, administration and disposal of all medication (whether or not prescribed). Staff must be made aware of this procedure. DS0000005521.V294757.R01.S.doc Version 5.1 Stoneleigh House Page 26 5 OP19 23 6 OP28 18 7 OP29 19 8 OP33 24 9 OP33 26 10 OP38 23 11 OP38 23 12 OP38 13 The registered person must ensure that there is a repair and refurbishment plan which identifies planned work and the date of completion. The registered person must ensure that staff progress on the NVQ training is monitored to maintain at least a minimum 50 of care staff with NVQ II or above. The registered person must ensure that all new staff are vetted in line with the requirements of the Care Homes Regulations 2001 as amended by the Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004. The registered person must ensure that a report is produced following a Quality Monitoring and Quality Audit process which takes into account the views of service users. The registered person must ensure that the home is visited at least once a month when a report is written on the running of the home in line with regulation 26 of the Care Homes Regulations 2001. This report must be available for inspection. The registered person must ensure that a fire risk assessment, and fire equipment and means of escape tests are appropriately recorded. The registered person must ensure that hoists and the lift equipment is appropriately tested by people competent to do so, and any identified remedial action is undertaken and recorded. The registered person must ensure that all risk assessments DS0000005521.V294757.R01.S.doc 01/08/06 15/07/06 01/07/06 01/09/06 01/07/06 01/07/06 01/07/06 01/07/06 Page 27 Stoneleigh House Version 5.1 are recorded and include the identified hazard, issues considered in reaching the risk management strategy, reviews of the effectiveness of the strategy and the people involved in the decision. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP16 Good Practice Recommendations The registered person should ensure that service users, or their representative, signs the care plan to confirm they are in agreement with it. The registered person should ensure that a central record is kept of all complaints which identifies the date of the complaint, the complainant, the nature of the complaint, a summary of action taken to investigate the complaint and the date the complainant was notified of the outcome. The registered person should ensure that staff sign and date the induction record as and when sections are completed. The registered person should ensure that when accident records are completed there is clarity about whether or not the accident was witnessed. 3 4 OP30 OP38 Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stoneleigh House DS0000005521.V294757.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!