Inspection on 06/09/06 for Taptonholme

This inspection was carried out on 6th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Taptonholme 17/01/09

Taptonholme 30/10/07

Taptonholme 02/03/06

Taptonholme 20/07/05

Taptonholme 22/03/05

Taptonholme 23/07/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Taptonholme 14 Taptonville Crescent Sheffield South Yorkshire S10 5BP Lead Inspector Mrs Claire McAuley Key Unannounced Inspection 6th September 2006 09:00 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 Taptonholme DS0000003021.V308722.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. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Taptonholme Address 14 Taptonville Crescent Sheffield South Yorkshire S10 5BP 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) 0114 266 3440 0114 266 3440 none Taptonholme Limited Miss Suzanne Victoria White Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2006 Brief Description of the Service: Taptonholme provides residential and personal care for up to 19 older people. The home is located in the Broomhall area of Sheffield close to local shops and public transport. Taptonholme is a large extended older property with accommodation over three floors. All bedrooms are single and two have ensuite facilities. The home is situated in its own grounds and has a large mature garden with seating areas. There is a small car park. The weekly fees are from £360.00 to £400.00. The home charges extra for hairdressing, toiletries, magazines, papers and holidays. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 6th September 2006 from 9.15am to 4.45pm. The inspector spoke to seven residents, four members of staff, one relative and the manager. A sample of records including menus, medication records, staff rotas, care plans, recruitment records, supervision, staff training, and procedures and policies were inspected and a proportion of the environment was checked. Five service users questionnaires were returned, and all confirmed that these residents were happy with the care offered. What the service does well: What has improved since the last inspection? What they could do better: A requirement to fit valves to water outlets to control the temperature and avoid the risk of scalding residents had not been completed. This was outstanding from the previous two inspections. (This work was completed before the inspection was published, therefore the requirement was removed). Not all residents had been regularly weighed as required from the previous inspection. Care plans did not include detailed information or action to be taken in relation to continence issues for individual residents and one care Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 6 plan wrongly indicated that a particular resident had no problems in this area. There were no individual risk assessments in place on care plans, and no formal reviews of residents took place. The resident or their relatives did not sign care plans, and there was no evidence of consultation. Residents had not been offered keys to their bedrooms. Some residents had not been consulted about their food choices. Records of staff training did not show all of the training that staff had undertaken. Supervision of staff did not take place at the required level. Residents had filled in questionnaires about the quality of the service in November 2005, but no results had been published. There were no residents or relatives meetings at the home, although the manager said that residents and relatives were asked what they thought of the service. The maintenance plan and development programme for the home was informal and not recorded. Some residents said there was not enough to do at the home and they were sometimes bored. The home’s environment was good in most areas, but the majority of toilets and bathrooms required refurbishment. Some carpets required replacement or cleaning, and some areas of the home, particularly doorframes, skirting boards, and corridor walls required redecoration. Only one bath was in use as there were no bath hoists fitted on any of the others. The manager indicated that a bathroom was to be converted to include a specialist bath. Toiletries were kept communally in a bathroom. 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. Taptonholme DS0000003021.V308722.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 Taptonholme DS0000003021.V308722.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in the outcome area is good. This judgement has been made using available evidence, and a visit to Taptonholme. Residents were not admitted to the home without their needs being fully assessed. This ensured that their health, social, and care needs were met. EVIDENCE: Two assessments of need were seen on plans of care. The manager confirmed that all residents now admitted to the home had an assessment of needs completed before their admission. This confirmed that the service was appropriate for the resident and provided staff with the information to formulate an individual plan of care. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 9 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 good. This judgement has been made using available evidence, and a visit to Taptonholme. Plans of care were in place for each resident. The information included was insufficient to ensure that the staff could fully meet resident’s needs including a lack of individual risk assessments. Plans were not signed, and formal reviews did not take place. There was evidence that a range of healthcare professionals regularly visited the home to meet the resident’s needs. To protect residents, a policy, procedure, and training for the safe administration of medication was in place. Risk assessments were in place for residents who were able to look after their own medication. Residents received personal support, which promoted their privacy, dignity and independence. EVIDENCE: Four care plans were checked in detail. They showed that a range of the required information was in place. However, there were no individual risk assessments in place, including risk of falling. One resident’s continence issues Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 10 had not been addressed, and their plan stated that there was no problem. There were no formal reviews of resident’s needs, although the majority of care plans were updated. There was no evidence of consultation with relatives, and the residents or their relatives did not sign the plans. Resident’s health needs were met, and the manager and residents spoken to confirmed that a number of health professionals visited the home. These included GP, chiropodist, dentist, optician, and district nurses. The nurses advised on continence issues and pressure care. One care plan showed that a resident had not been regularly weighed. Some nutritional screening of residents was evidenced. There was a medication policy and procedure to ensure that staff adhered to safe practices. Four resident’s medication records were checked and their medication had been stored and administered appropriately. Risk assessments for those able to self-administer medication were in place. Staff responsible for administering medication had received medication training. Residents and a relative said that they were happy with the care received. Staff spoken to were aware of the need to treat residents with dignity and respect and were observed interacting in a friendly and pleasant way with them. Residents said they had not been offered keys to their rooms. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence, and a visit to Taptonholme Routines of daily living were flexible and suited residents individual choices and preferences. Residents were supported in maintaining contact with relatives and visitors at any reasonable time. Resident’s choice was promoted by the personalisation of their rooms. A good menu was offered and specific dietary needs were catered for. However resident’s rights were not promoted, as they were not fully consulted about their food preferences. EVIDENCE: Residents confirmed that the routines of daily living were flexible and suited their individual choices and preferences. There was no written formal activities programme in place at the home, although activities, including trips out to Bakewell and Knowsley Safari Park took place, and those residents who were able to take part, enjoyed them. Entertainers also came in to the home, and a University Volunteers Group. There were coffee mornings and sometimes, arts and crafts. There was a communion service at the home. A number of residents spoken to said they were bored and that there was not enough to do. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 12 Although resident’s interests were noted in their care plans, there were no individual plans of activities in place for them. Staff spoken to said that residents were not interested in doing anything. Residents said that their relatives and friends were able to visit the home at any reasonable time. One visitor who visited the home on a regular basis said they were always offered a drink and the staff were always very welcoming. Residents were supported by staff to access facilities in the local community and were often accompanied out to local shops or for a walk. Residents were able to personalise their rooms with items brought from home, and this contributed to their comfort and well being, creating a homely environment in their rooms. The inspector observed lunch being served, and the food was wholesome and nutritious. Individuals were helped as appropriate. The menus were varied, and there were plentiful supplies of fruit and vegetables included. The cook had a good knowledge of individual needs. There were no special diets at present, but she indicated that she was able to provide special diets if anyone needed them. Residents said they were mostly happy with the food, but a couple said they were fed up with having sandwiches at teatime. Most residents spoken to said they had what was offered and were not consulted about menus, although they were asked what they wanted and could have an alternative if requested. Cooked breakfast was not offered except on a Saturday. The reason given for this was that food would be wasted at lunchtime if the residents had cooked breakfast. The home had received an award for food hygiene and cleanliness in the kitchen. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence and a visit to Taptonholme. A complaints procedure was in place to protect residents. Residents were protected from abuse by the awareness of staff through training and the home’s procedure and policy. EVIDENCE: The complaints procedure ensured that residents and their relatives were aware of how to make a complaint and who would deal with it. The manager said that no complaints had been received since the last inspection. The complaints procedure did not include a statement to say that complaints would be dealt with within 28 days. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. The staff had received adult protection training. The manager said the programme of training was ongoing. There had been no incidents of abuse. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to Taptonholme. In the main, the home’s environment was clean, well furnished, and homely for residents. However, some areas of the home required redecoration, new carpets and refurbishment, and unpleasant odours removing. Most toilets were in poor condition. EVIDENCE: The home’s lounges, dining room, kitchen, hall and stairs, and the majority of bedrooms seen were of a good standard of cleanliness and were comfortable, and well furnished and decorated. Parts of the corridor walls on all floors were chipped and scraped, as were the skirting boards and doorframes. The smoking room carpet was stained and had numerous cigarette burns, and a chair was damaged. A carpet on the top floor landing was badly stained, had an unpleasant odour and did not fit. A bedroom carpet was stained, and in two bedrooms there was an odour of incontinence. The manager said that there Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 15 was no formal programme or record of maintenance and renewal in place, although an informal programme was carried out. The grounds to the home were well maintained and accessible to residents. Residents said that they enjoyed spending time in the garden area during the summer months. The majority of toilets required refurbishment. Decoration of walls doors and ceilings was shabby, and the flooring, including some carpeting, was stained in places. Tiles, toilets, toilet seats and particularly units around washbasins were in poor condition. One toilet wall had cracks around the window. Bathrooms would also benefit from redecoration and refurbishment. The manager stated that a top floor bathroom was being converted to take a specialist bath. Only one bath is used at the present time, as it is the only one fitted with a hoist. She said that residents did not like having showers. Resident’s toiletries such as talcum powder were kept together communally in a bathroom, and were not individually identified. In the main, the home was clean and pleasant. Two residents rooms and the top floor landing carpet had an unpleasant smell. Laundry facilities were sited away from food areas. There were policies and procedures in place for the control of infection and staff were aware of these. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence and a visit to Taptonholme. There were sufficient staff on duty to meet the residents needs. Staff had received training to meet the resident’s general and specific needs including over 50 of staff with NVQ2 or above. However, records of staff training were incomplete. There was a recruitment policy and procedure in place, which protected residents. EVIDENCE: Staff rotas showed that there were sufficient staff employed to meet the needs of the residents. This was confirmed by the residents who also said they thought staff were ‘good’ and ‘kind’. Staff members confirmed that there were usually enough staff, except sometimes at holiday times and if there was staff sickness. Regular bank staff were used to cover at these times. Staff said they worked well together as a team and enjoyed working at the home. On the day of the inspection there was a vacancy for a domestic, and care staff had been doing the cleaning. The manager indicated that this was being advertised and hopefully the post would be soon filled. The manager confirmed that 57.6 of the staff had completed an NVQ2 or above qualification. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 17 There was a recruitment procedure in place. Staff files had been updated to include all the relevant information including a staff photograph and employment history. Staff confirmed that they had attended various training courses that including food hygiene, moving and handling, fire, and first aid. The manager confirmed that new starters had received an induction programme delivered by an outside provider that met Skills for Care standards. New starters also attended the home’s induction. Staff confirmed that the training was good, and included specialist training on areas such as epilepsy. The records that were kept of the staff training were confusing and incomplete, and did not indicate who had received updated training. Therefore it was not possible for the inspector to check which training the home had provided, or if it was up to date. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to Taptonholme. The manager’s qualifications and experience promoted a welcoming and relaxed environment for residents and staff. The quality assurance system did not adequately consult the residents or their relatives in order to measure the success in meeting the aims of the home. The financial systems promoted and protected resident’s interests. Supervision of staff was not completed at the required level and this could affect the health and welfare of the residents. Risk assessments and other measures were in place to protect residents. EVIDENCE: The manager had been in post for several years and had completed the registered managers award and a NVQ level 4 qualification. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 19 The atmosphere within the home was relaxed and welcoming. The quality assurance system required development. Regulation 26 visits took place, but there was no formal system of seeking resident’s views on the service. Questionnaires had been sent to residents asking their views in November 2005, but the results had not been published. No residents or relatives meetings took place. There was no written development or maintenance plan for the home, although there was a system of informal maintenance in place. Relatives dealt with the majority of resident’s finances, but some residents looked after small amounts of their own money so they could purchase items such as papers, and hairdressing services at the home. Accounts were kept, and these were appropriately recorded and audited. Records checked showed that supervision of staff did take place, but not at the required level and did not include training needs for some staff. A requirement to fit valves to water outlets to control the temperature and avoid the risk of scalding residents had not been completed. This was outstanding from the previous two inspections. (This work was completed before the inspection was published, therefore the requirement was removed). The manager confirmed that risk assessments on water temperatures were in place, and there were regular checks on taps. She also said that staff checked water temperatures with a thermometer before each resident had a bath. The manager said that work to fit valves was due to start on 11th September 2006. The staff had received training to promote the health, safety and welfare of residents and their colleagues. Servicing and maintenance of electrics and equipment was in place. Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13 Requirement Individual risk assessments must be put in place on all resident’s care plans, including the risk of falling. All resident’s needs must be fully assessed and met, including continence issues. All residents must have their overall care reviewed yearly. They and their relative/representative must be consulted in this process. All residents must sign care plans, or if they are not able, their relative or representative must sign the care plan. All residents must be regularly weighed and their weight recorded. (Timescale of 30/05/06 not met) Residents must be consulted on their choice of food at teatime and they must be made aware that alternatives to sandwiches are available for them. A rolling programme of refurbishment and redecoration for the home must be put in place. Work undertaken DS0000003021.V308722.R01.S.doc Timescale for action 01/12/06 2. 3. OP7 OP7 13 12 14 15 01/12/06 01/12/06 4. OP7 14 15 01/12/06 5. OP8 15 01/12/06 6. OP15 16 12 01/12/06 7. OP19 23 01/06/07 Taptonholme Version 5.2 Page 22 8. OP19 23 9. OP19 23 10. 11. OP21 OP21 23 12 12. OP26 23 16 12 13. OP30 17 18 14. OP33 24 15. OP36 18 must be recorded. Redecoration of corridors, walls, doorframes and skirting boards must be completed as part of an ongoing programme. The smoking room carpet and damaged chair must be replaced. The stained carpets on the top floor landing and a resident’s bedroom must be cleaned to remove the odour and staining, or replaced. Toilets must be refurbished as part of a rolling programme. Resident’s toiletries must not be communally stored in bathrooms. They must be returned to identified individuals and kept in their rooms. Continence programmes for residents, and hygiene control procedures must be revised, and action taken to remove the odour from areas of the home. Staff training records must include details of all training undertaken including adult protection. The record must be made available for inspection by the CSCI. A quality assurance system must be developed to ensure that the views of residents and relatives are sought, and that results of these consultations are published. Supervision of staff must take place at the required level of 6 times a year. 01/06/07 01/12/07 01/06/07 01/10/06 01/12/06 01/12/06 01/12/06 01/12/06 Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP10 OP12 Good Practice Recommendations All residents should be offered keys to their rooms The programme of activities should be developed to include a wider and more frequent range of activities. Residents should be consulted on their preferences, and activities provided should be recorded and monitored. Residents should be offered the choice of a cooked breakfast each day if they wish it. The complaints procedure should contain the statement that complaints will be dealt with within 28 days. The planned refurbishment of the bathroom should be completed, so that there is more than one bathroom available for resident’s use. 3. 4. 5. OP15 OP16 OP21 Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Taptonholme DS0000003021.V308722.R01.S.doc Version 5.2 Page 25 - 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. 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