Inspection on 05/12/06 for The Close

This inspection was carried out on 5th December 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

The Close 18/09/08

The Close 01/11/07

The Close 12/06/06

The Close 03/10/05

The Close 26/04/05

The Close 17/01/05

The Close 07/07/04

The Close 24/02/04

Similar services:

Fairfields Country Rest Home

Fairfax House

Claremont Nursing Home

Doveridge Care Home

Dunmore

Chatsworth

Dunraven Lodge

Eastleigh Care Homes, South Molton

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Close (The) The Close Littleton Panell Devizes Wiltshire SN10 4ES Lead Inspector Bernard McDonald Unannounced Inspection 5th December 2006 09:20 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 Close (The) DS0000028334.V317633.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. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Close (The) Address The Close Littleton Panell Devizes Wiltshire SN10 4ES 01380 812304 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) Mr John Roche Mrs Aurora Roche Mrs Aurora Roche Care Home 12 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (12) of places Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th June 2006 Brief Description of the Service: The Close is a privately run home that provides personal care and accommodation for up to 12 people with dementia. One of the owners also manages the home. Both the owners are closely involved with the home on a regular basis. The Close is situated in the village of Littleton Panell, which is close to Devizes. There are local shops, pubs and a GP surgery nearby. The Close is a detached house set in its own grounds. The service users’ bedrooms are on the ground and first floors. A passenger lift is available. There is a lounge that is also used as a dining room. Access to a smaller dining room and a conservatory is either through the kitchen or off the main hallway. The conservatory is a smoking area and can be used to receive visitors. There are eight single bedrooms and two shared bedrooms. None of the rooms have en-suites, but all have hand washbasins. Commodes are provided in the bedrooms. There are three bathrooms, one of which has a hoist. There are six toilets for service users. There are at least two staff working during the day. At night there is one waking staff member and another person who provides ‘sleeping-in’ cover. The scale of charges as at 22 May 2006 was £379 - £455. Close (The) DS0000028334.V317633.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 over seven and three quarter hours. As part of our site visit we met with all service users. In addition there was opportunity to meet with two relatives who were visiting the home at time of our visit. As part of our inspection methodology, comment cards were sent to service users, their representatives and health care professional. No adverse comments were received. The care plans of four service users were examined in detail. In addition medication records, staff recruitment files, training records, health and safety documents and a sample of risk assessments were examined. A tour of the building was made and accompanied by one member of staff all service users bedrooms were seen. Three members of staff were interviewed in private. Mr Roche the registered provider was present throughout the majority of our site visit. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: Service users commented favourably on the care they receive. Comments such as, “staff are very good” and “ I like living here” were made during our visit. The relatives of service users are welcome to visit at anytime. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 6 Health care needs are being addressed and the home has established a good working relationship with district nurses and the local health care practice. One health care practitioner commented favourably on the care their “patients” received. Observations made during the site visit showed staff interacting with service users and spending time with them throughout the day. An activity programme is in place and every effort is made to ensure some recreational activity takes place each afternoon. What has improved since the last inspection? What they could do better: The home needs to improve their admission procedures to ensure service users needs are assessed prior to admission. Service users need to receive accurate information on the service being provided and the actual cost of their stay. The statement of purpose needs to be updated to fully reflect the service being provided paying particular attention to the policy on emergency admissions. Service users contracts need to be updated annually. The home needs to look at ways of involving service users in all aspects of their care. In particular more attention needs to be given to how service users can be involved in the development of their care plan and what support can be made available to assist service users who may wish to make a complaint. Risk assessments need to be completed on the prevention of tissue damage. To fully ensure service users’ right to privacy is upheld suitable locks which allow access to staff in the event of an emergency should be fitted to all bathroom and toilet doors. To ensure service users are not socially isolated, attention needs to be given to involving service users in the local and wider community. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 7 Parts of the fabric of the home are beginning to show signs of wear and tear, in particular a communal carpet needs to be replaced and paintwork needs attention. The identification of staff training needs should be addressed to ensure staff receive the necessary training for the work they perform. The home needs to implement an effective quality assurance system based on seeking the views of service users and their representatives as a way of improving the quality of care to service users. 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. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home needs to improve their admission procedures to ensure service users needs are assessed prior to admission. More attention needs to be given to ensure service users contracts reflect the cost of their stay. The home must ensure the statement of purpose specifies the service being offered. EVIDENCE: The care files of two service users who were recently admitted to the home were examined in detail. The records showed the home had not received an assessment of the needs of the service users prior to them moving into the home. Mr Roche stated this was due to one service user being admitted as an emergency and only verbal information was received over the telephone. The homes statement of purpose does not specify emergency admission can be accommodated. The second service user had been using day care facilities at the home while waiting for a vacancy. The absence of any formal assessment Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 10 of the needs of service users means the home cannot ensure they can safely meet the needs of service users being admitted. Mr Roche stated it is the policy of the home to provide service users or their family with a copy of the service user guide but there was no record to demonstrate this had been given. Two service users and the relative of one service user could not recall if they had received a copy of the guide. Service users were not aware of the cost of their stay at the home. Contracts that were examined also did not specify the actual cost. One contract had not been updated since 1997. These matters were brought to the attention of Mr Roche who confirmed service users contracts had not been updated. The relative of one service user commented their son dealt with financial matters. The home does not provide intermediate care. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 11 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. While care plans reflected service users needs more attention needs to be given to involve service users in the development of their care plan. Risk assessments need to be completed on the prevention of tissue damage. The service users’ right to privacy is not always upheld. Medication is being safely managed. EVIDENCE: Four service users case files were examined in detail, which included two service users who were recently admitted to the home. Each service user had a plan of care covering areas of personal care and medical intervention. Care plans specified what care and intervention staff should provide to support service users in their daily living. Service users were complimentary about the care provided by staff. The relatives of two service users commented favourably on the care being provided. One relative commented that staff are “very good.” Observations made during the site visits showed staff taking time Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 12 to explain to service users tasks that were being undertaken and spending time talking to service users. Since the last inspection service users daily notes now make reference to the service users care plan which ensure staff focus on the needs of service users in writing up their daily notes. In addition short term care plans are now put in place for service users who require specialist intervention such as chest infections and urinary tract infections. Care plans that were examined had been reviewed on a monthly basis. Where possible the relative or representative of the service users attend their six month or annual care review. Less evident was how service users are involved in this process and how they are made aware of the contents of their care plan. No formal assessment of the risk of pressure damage has been completed by the home as required at the last inspection. While records indicate that service users who present with the indications of pressure damage are referred to the district nurse, the lack of detailed risk assessments could result in service users being placed at unnecessary risk. Following a requirement made at the last inspection new signage has been placed on toilet doors to indicate whether the toilet is engaged. This is not sufficient to ensure service users dignity and respect is maintained. Observations made during our visit showed the signage indicating the toilet was engaged when it was not and one service user entered one toilet while the sign showed it was engaged. To ensure service users privacy is maintained when using the toilets, appropriate locks that allow access to staff in the event of any emergency should be fitted to all toilet doors. Service users are registered with the local health care practice. Comments received from one General Practitioner indicated they were “ impressed with the quality of care and performance of staff” with regard to their patients. A sample of medication records were examined. Records showed medication was being accurately recorded and stored securely. The majority of staff have completed the safe handling of medication course. Close (The) DS0000028334.V317633.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. Service users are encouraged to take part in activities in the home but more attention needs to be given to involving service users in the local and wider community. Mealtimes are relaxed and unhurried offer a varied choice. Visitors are made welcome. EVIDENCE: There is a planned programme of activities that take place each day. Discussion with staff and service users confirmed that these normally take place in the afternoon. Observations made during our site visit found staff organising a large group activity with service users after lunch. Service users were encouraged to participate and from direct observations appeared to enjoy the activity. Less evident was service users ability to access the local and wider community. Discussion with staff confirmed service users rarely go out into the community. This clearly impacts on service users ability to go personal shopping, attending local events and meeting other people and can lead to service users being socially isolated. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 14 Service users spiritual needs have been addressed as part of the care plan. Two service users confirmed the local clergy visits the home. One service user commented they did not want to attend a church service. There was opportunity to meet with the relatives of two service users. One relative commented they are always made to feel welcome and can “visit at anytime”. One person commented they feel their relative is “well cared for”. Mr Roche confirmed that the home does not act as agent for any service users benefits. The responsibility for managing service users monies is left with the service user or their representative. Copies of two weeks menus were examined. The menu showed the main meal of the day is provided at lunchtime and consisted of a meat or fish dish. Staff are responsible for the preparation and cooking of meals. Mr Roche stated there are no plans to employ a cook. One member of staff confirmed that service users likes and dislikes are known but if a service user was to refuse a meal then an alternative choice would be offered. Part of the lunchtime meal was observed. Where service users required assistance with their meal this was provided in a discreet manner. Service users had a choice of where to eat their meal. Service users commented favourably on the standard of meals provided in the home. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 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. 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 home is making every effort to ensure service users are protected from abuse but consideration needs to be given to how service users can be supported to fully understand and use the complaints procedure. EVIDENCE: The complaints procedure states any complaint would be responded to in 28 days. A copy of the procedure was available in the home. From discussion with service users it was difficult to evidence if they had been made aware of how to make a complaint. In practice the majority of service users would require support to make a complaint and the home should consider how this could be provided. Comment cards received from health care professional and relatives confirmed they were aware of the homes complaints procedures. No complaints have been made about the service since the last inspection. Discussion with staff confirmed they had received training in abuse awareness and certificates were available to demonstrate completion of the training. Staff confirmed they would raise any concerns about the welfare of service users with the manager or Mr Roche. Policies and procedures are in place for the protection of vulnerable adults. There is a whistle blowing policy if staff wish to use it. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 25, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and free from odour but the fabric of the building was beginning to show signs of wear, which now needs to be addressed. EVIDENCE: A tour of the building was made and accompanied by a member of staff all service users rooms were seen. There is a large communal room, which on the day of our site visit was being used by the majority of service users. In addition there is a smaller sitting area that leads to a large conservatory. The variety of communal areas provides service users with a choice of whether to spend time on their own or in the company of others. Some areas of the home were beginning to show signs of wear. In particular the carpet in the large communal area was threadbare in places and would Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 17 benefit from being replaced. Paintwork was chipped and wallpaper was torn. The home has however purchased new chairs for the communal lounge. Toilets and bathrooms are situated over two floors. Only one bathroom and none of the toilet doors had any locks fitted to ensure service users privacy when using these facilities. Radiators are not guarded and following a requirement at the last inspection a risk assessment has been completed regarding service users safety. However in view of the frailty and confusion of service users it is strongly recommended that guards are fitted on all radiators. The laundry facilities are sited in a separate building. The floors and walls are easily cleanable to reduce the risk of infection. Staff are due to commence infection control training in the next few weeks as part of a distance-learning course. The works books have already been received and were available at the home. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Safe recruitment practices are being followed and good progress has been made in ensuring staff have access to NVQ training. However more attention needs to be given to identifying staff training needs and ensuring the home have up to date information on current training practices. EVIDENCE: Examination of the rota shows two members of staff on duty at all times. In addition one extra member of staff is on duty to assist at meal times. The rota does not show which member of staff provides sleep in cover at night, however discussion with one member of staff confirmed the arrangements that are in place. Mr Roche confirmed the rota had been updated since the last inspection to reflect the hours worked by the manager. There are currently no staff vacancies. One relative commented that the staff are “very good” and “couldn’t be better”. Discussion with staff on duty confirmed they had received training in dementia care and more than 50 of staff have completed a National Vocational Qualification (NVQ). One member of staff has recently completed NVQ 4. The lack of available records made it difficult to fully evidence what training staff had received. Following a recommendation made at the last inspection Mr Roche has not completed an individual training plan or obtained information on Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 19 the changes that are being made to induction standards. The recommendations made in the last report will remain. The recruitment records of three recently appointed staff were checked. Improvements have been made to the recruitment practices adopted by the home. All staff had received a satisfactory Criminal Records Bureau check (CRB) and Protection of Vulnerable Adults check (POVA) prior to commencing work. In addition two written references and a proof of identity had also been received. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The future managements arrangements need to be clarified and more attention given to implementing an effective quality assurance system. Some improvements have been made to ensure service users health and welfare is being considered, however more work is required to ensure they are adequately protected from all risks to their safety. EVIDENCE: The registered manager/co owner was not working on the day of our site visit, however Mr Roche, the joint owner was available for the majority of the visit. The requirement made in relation to the training needs of the registered manager will be carried forward to the next inspection. Mr Roche stated that there are plans to change the current management arrangements. Mr Roche Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 21 has already completed NVQ 4 in care and plans to register as the manager in the near future. Mr Roche confirmed the home does not keep any money on behalf of service users. Risk assessments have been completed on window openings and radiator guards. While window restrictors have been fitted the outcome of the risk assessment for radiator guards found a low risk to service users. However the risk assessment only took into consideration service users mobility and the position of the radiator. To fully ensure the safety of service users it is strongly recommended that covers be provided for all radiators. The home has recently purchased a Health and Safety management system. As part of the package an independent Health and Safety audit will be completed in the new year. There was evidence to demonstrate staff have received training in first aid and moving and handling. A fire safety check was completed on the day of our site visit. Records show fire safety drills are taking place every three months. Since the last inspection little progress has been made in meeting the requirement in relation to quality assurance. The timescale for compliance had not expired and this will be brought forward to the next inspection. Records in relation to staff supervision have improved and demonstrated the manager is meeting with staff on a more regular basis. A sample of supervision records were examined and showed that training issues and care duties are discussed though the recording is limited. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 1 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 X X X X 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X N/A 3 X 2 Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 23 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(1)(a)(b) (c) Requirement The registered person must ensure the homes statement of purpose clearly specifies the criteria for admission including the homes policy for emergency admissions. The registered person must not provide accommodation to a service user unless the service user has been assessed by a suitably qualified or trained person and they have obtained a copy of the assessment to ensure they can safely meet their needs. Assessments must be carried out concerning the risk of service users developing pressure sores. This was a requirement at the last inspection. The timescale given was 13/08/06. Arrangements must be made which will ensure that the home is conducted in a manner that respects the privacy and dignity of service users. This was a requirement at the last inspection and relates to the DS0000028334.V317633.R01.S.doc Timescale for action 01/02/07 2. OP3 14(1)(a) (b) 01/01/07 3. OP7 15 01/02/07 4. OP10 12(4)(a) 01/02/07 Close (The) Version 5.2 Page 24 5. OP27 17(2) 6. OP31 10(3) 7. OP33 24 provision of new signs toilet doors and new locks being fitted. The timescale given was 28/06/06. While toilet doors do now have signs new suitable locks allowing staff access in the event of an emergency are now required. The registered person must ensure the staff roster shows full details of who has responsibility for sleeping in duties. The manager must undertake training from time to time as is appropriate and must inform the Commission of the arrangements that have been made for this. This requirement has been carried forward from the last inspection. The timescale for compliance was 30/09/06. The home’s system of quality assurance must ensure that it includes an evaluation of the quality of service provided and complies with Regulation 24 of the Care Homes Regulations 2001. The Commission must receive a report that is based upon the system. 01/01/07 01/01/07 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP2 OP7 OP12 Good Practice Recommendations The registered person should ensure the service user contract clearly reflects the cost of their stay. The registered person should ensure as far as possible service users are involved in the development of their care plan. The registered person should ensure service users are DS0000028334.V317633.R01.S.doc Version 5.2 Page 25 Close (The) 4. 5. 6. 7. 8. 9. OP16 OP19 OP19 OP25 OP30 OP30 10. OP33 provided with opportunities to access the local and wider community. The registered person should ensure service users are fully aware of how to make a complaint. The registered person should consider replacing the carpet in the large communal lounge. The registered person should ensure that areas in need of new paintwork are decorated. It is strongly recommended that the registered person takes action to ensure radiators are guarded or have low surface temperatures. The registered person should ensure that the details of staff training and related activities are maintained in an individual record for each staff member. The registered person should ensure that information is obtained from ‘Skills for Care’ (www.topssengland.net) about the changes that are being made to the induction standards and how this will affect the induction that new staff members receive in the future. The registered person should ensure that the policy and procedure for quality assurance is amended to include the arrangements made for annual development and for reviewing the quality of service provided in the home, in accordance with Regulation 24 of the Care Homes Regulations 2001. Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Close (The) DS0000028334.V317633.R01.S.doc Version 5.2 Page 27 - 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!