Inspection on 13/07/07 for The Larches

This inspection was carried out on 13th July 2007.

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

The inspector 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 Larches 14/07/08

The Larches 18/12/07

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE The Larches Canal Hill Tiverton Devon EX16 4JD Lead Inspector Dee McEvoy Key Unannounced Inspection 09.15 13th & 16th July 2007 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 The Larches DS0000070349.V345402.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. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Larches Address Canal Hill Tiverton Devon EX16 4JD 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) 01884 257355 01884 253270 Anne Gray Care Limited ****Post Vacant**** Care Home 20 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (20), Physical disability (20) of places The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia (Code DE) Physical disability (Code PD) The maximum number of service users who can be accommodated is 20. 16th & 17th August 2006 2. Date of last inspection Brief Description of the Service: The Larches is a residential home registered to provide care to 20 people. The categories of registration are for females of 60 years of age falling in no other category, and people over 65 years of age with or without dementia or a physical disability. The home is situated on the outskirts of Tiverton with views of the surrounding countryside. The home has 4 floors linked by a lift. There are two lounges with a dining area and conservatory attached to one. Eleven rooms have en-suite facilities; and there are two double rooms. The home has a pleasant garden area with seating. There is a new fee structure for the home. At the time of inspection the average cost of care ranged between £475.00 and £550.00 per week depending on individual needs. Additional costs, not covered in the fees, include chiropody, continence products, hairdressing, outings and personal items such as toiletries and newspapers. Current information about the service, including CSCI reports, is available to prospective residents. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection the manager completed an Annual Quality Assurance Assessment (AQAA), which contained general information about the home and the people living there. With the information provided, CSCI surveys were sent to people living at the home, their relatives, staff and outside professionals, prior to our unannounced site visit. The activities co-ordinator at the home helped all people to complete CSCI surveys and we were told that the majority of people could not complete questionnaires without help. Surveys were received from 10 people living at the home; four relatives, three health and social care professionals and five staff members. Their comments and views have been included in this report and helped us to make a judgement about the service provided. We spent 14 hours at the service, over a period of two days. At the time of our visit there were 18 people living at the home with two vacancies. To help us understand the experiences of people living at this home, we looked closely at the care planned and delivered to four people. Most people living at the home were seen or spoken with during the course of our visit and five people were spoken with in depth to hear about their experience of living at the home. During our visit we spoke with 4 relatives and nine members of staff, including the manager and responsible individual, to hear what they think about this service. The home provides care for people with a dementia related illness and some people do not have the capacity to communicate fully or understand the inspection process. We spent considerable time observing the care and attention given to these people by staff. During this visit an Environment Health Officer (EHO) joined us to look at the risk to people posed by hot water. Following this inspection an improvement notice was issued by the EHO in relation to hot water temperatures. Once the inspection was completed our findings were discussed with the acting manager, responsible individual and company director. We found some areas of concern, for example care planning, the management of risk and the management of medicines, which the home needed to action urgently to comply with the regulations, and safeguard people who use this service. A letter was sent to the responsible individual following the inspection asking her to tell us in writing by 30 July 2007 what they are doing to deal with these areas of concern. We received a response from the provider on 30/7/07, which indicated that some of the issues were being addressed. A random inspection was carried out on 16 & 17 April 2007 in order to look at how the improvements required at the last key inspection were being met. A The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 6 copy of this report can be obtained from the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? It was good to see that a number of improvements have been achieved since the last key inspection. The home has employed an activities co-ordinator for 6 hours a week, who is beginning to develop interesting and meaningful activities for people. People told us how much they had enjoyed the opportunity to do some cooking again. It is expected that this area of care will continue to develop and provide people with regular stimulation and occupation. Several areas of the home have been re-decorated and new carpet and flooring have been laid in the communal areas. This has improved the general environment considerably for people, who told us how much they liked and The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 7 appreciated the improvements. Since the last key inspection a considerable amount of work has been undertaken to make the home safe for people. Radiators have been covered to reduce the risk of burning and thermostatic valves have been fitted to most taps to ensure safer water temperatures. New equipment, such as a standaid and two wheelchairs, has been purchased to help staff deliver care. Staff told us this had improved the care delivered to people and helped them to meet individual needs. Recruitment has improved with the home now receiving proper proof of the suitability of staff to work at the home, which ensures that people are appropriately protected. There have been some areas of improvement in the general standard of hygiene with anti-septic gels being used in toilets without hand-washing facilities. Fire safety has been improved by the up-grading of fire doors in line with current legislation and fire doors now close properly. What they could do better: Sixteen requirements have been made as a result of this inspection, three relating to health and safety training issues. Seven requirements are outstanding from previous visits. People living at the home must have a detailed care plan and risk assessments describing how their individual needs are to be met, to help staff to provide consistent and safe care. The home must monitor people’s health needs robustly and ensure that accurate records are kept of people’s nutritional care needs and ensure that people are weighed regularly to monitor health needs properly. Aspects of the management of medicines must be addressed so that practices are safe and peoples’ wellbeing is ensured. In order to fully protect people living at the home from the risk of harm or abuse all staff must be aware of the adult protection procedures. Staff must receive appropriate training. The current bathing facilities do not meet the needs of people living at the home and must be improved. The home has been awarded a considerable sum by Devon County Council to improve these facilities and quotes for the installation of a wet room are currently being obtained. Further action is required to ensure that a safe environment is maintained for people in respect of hot water temperatures. The home must implement the actions highlighted in their risk assessment of the garden to ensure that people can enjoy the garden safely. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 8 The home needs to improve infection control practices. The arrangements for cleaning commodes are not satisfactory, some staff displayed poor infection control awareness and the sharing and cleaning of hoist slings at the home needs to be addressed. Staff have not received formal infection control training to ensure their practice maintains good standards. The deployment and number of staff on duty is not always sufficient to ensure that peoples’ needs and preferences are met in a timely way. Staff do not appear to have sufficient time to undertake other responsibilities such as reviewing care plans, monitoring people’s weights or spending time talking with people. Staff must receive relevant training to enable them to meet the needs of people with a dementia type illness. Staff should also receive a structured induction training to help them understand how the home works and how to care for people respectfully and safely. The person employed to manage this service has been in post for 10 months but has not made an application to register with the Commission, which is intended to ensure the home is consistently well managed. The responsible individual for the company must carry out regular required monitoring, to ensure people are receiving an appropriate service from the home. In order to maintain good health and safety practices staff require mandatory training in manual handling, food hygiene and infection control. 13 recommendations have been made to ensure good practice and standards are maintained. In order to ensure that people’s rights are properly protected contracts of residence should be reviewed and re-issued, and people should be made aware (where possible) of the terms and conditions of their stay. The home has been asked to improve the information contained in people’s initial assessments in order to improve care planning and delivery. Daily notes about the care delivered to people should be accurate and respectful. It is recommended that the home continue to develop further opportunities for recreational activities, which suit people’s needs, preferences and ability. The home has been asked to do more to promote individual choice, particularly for those people with a dementia type illness. To encourage safe working practice risk assessments should be completed in relation to moving equipment around the building. To promote good infection control practice, the home should consider obtaining individual slings for people requiring assistance to mobilise. The home uses an annual satisfaction survey for people living at the home to monitor the quality of the service. In view of the number of people who could not comment on the care they receive, we have recommended that relatives and health and social care professionals are included in the annual survey. Staff should receive regular one to one supervision in order to review their practice and learning needs. An audit of accidents and incidents should be The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 9 made to help the manager identify any trends and allow her to put measures in place to reduce risks. 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. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 10 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 The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although information about The Larches is provided to some people considering a move, which gives them an idea of what the home offers, some initial assessments do not contain sufficient information to enable staff to fully plan and deliver care. EVIDENCE: Surveys from people living at the home showed that five of the ten had received enough information about this home before deciding to move in. Three people felt they had not received enough information and two couldn’t remember. Two of the four relatives responding with surveys said they had received enough information about the home; two had not. The home has a Statement of Purpose to help people understand what to expect of the home and help them decide if it will be right for them. The manager told us that prospective residents of the home, or their relatives, are given a copy of the statement of purpose and the latest CSCI report is available in the hallway. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 12 Prospective residents of the home, or their relatives are given a tour of the home, a full explanation of what the home provides and an opportunity to ask any questions. We were told that a copy of the statement of purpose and the latest CSCI report is also given to people. Four people responding with CSCI surveys couldn’t remember whether they had received a contract and four people said they had not received a contract. Three contracts were looked at to ensure that people’s rights were protected; they contained reference to ‘requirements of the National Assistance Act and Devon County Council’ rather than to more recent legislation and standards. The contracts were also between the company’s responsible individual and people living at the home and rather than between the home and individual people. Contracts generally set out people’s rights and responsibilities and the company’s representative assured us that all people resident at the home were issued with contracts. Care files showed that some information is gathered before people decide to move in, including assessments carried out by health and social care professionals in some cases. The home, usually the manager, completes their own assessment, which includes basic details of the individuals’ personal and health care needs. Some areas of the assessments had not been fully completed, for example people’s communication needs and emotional needs, social interests, hobbies and spiritual needs, meaning that some needs may not be planned for and successfully met. There were letters on two files confirming that the home could meet the assessed needs of the individuals. Two outside professionals said care assessment arrangements ensured that accurate information was gather about people’s needs and that the right service is planned and given to individuals; one said they felt this was “usually” the case. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 13 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 poor. This judgement has been made using available evidence including a visit to this service. Generally care plans, risk assessments and health care needs are not recorded or monitored to a good standard and the management of medication is not satisfactory. EVIDENCE: Some people were unable to tell us about the care they received but five people told us they were happy with the care, one said, “I get the help I need”. CSCI surveys showed that all people responding felt they received the care and support they needed. Relatives told us they were generally happy with the care provided at the home, one wrote, “Staff treat people as one of the family and try to help my husband” and “I do not find any fault at all with the home”. Another relative told us, “My aunt is being looked after well”. Health and social care professionals said that “people seem to be well cared for” and “Generally The Larches seem to do a good job”. Care plans are currently developed and written by the manager. There was some evidence that people had been consulted about their care needs in one The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 14 care plan but not in others; Three of the care plans had not been signed by the individual or the person completing it to indicate consultation. Care plans did not include details of people’s preferences in relation to food, drink and bed times but had comments such as “normal” under preferred diet (Refer to standard 14). Care plans looked at contained some basic information about people’s needs and some action for staff to take to meet those needs but this mainly focused on their personal care needs. There was no record of some people’s means of communication – particularly relevant to those people who have difficulty in communicating. A care plan for someone who got agitated did not include possible triggers – information that might help staff minimise this person’s aggression. Daily notes for one person said they had reddened skin, but this had not been reflected in the care plan and a relevant risk assessment tool had not been reviewed recently to indicate any improvement or otherwise. This could lead to deterioration in their health and inconsistent practice by staff. People’s emotional and psychological needs had not been addressed, for example a social services assessment highlighted possible unresolved grief for one person, which could be contributing to depression. The home’s care plan did not mention this problem and there was no guidance to help staff address this person’s needs in relation to bereavement. Staff are asked to report and record any changes to people’s needs so that care plans can be reviewed. This is not happening consistently and although care plans looked at had been reviewed recently they had not been reviewed regularly to reflect changing needs or behaviour. The manager and staff told us that restrictions on their time meant that care plans and other records were not always accurate. Not all behavioural risks had been assessed, for example aggression or antisocial behaviour such as ‘exposing’ oneself in public, which could result in staff not taking the appropriate action to protect people and themselves from certain behaviour. Daily notes showed that staff responded in different ways when dealing with challenging behaviour with varying degrees of success. A behavioural chart was in place to help the staff and other health professionals begin to understand certain behaviour and how best to manage it, but these records were poorly completed and didn’t consider triggers or positive actions to deal with difficult situations. Another risk assessment highlighted that the person had a tendency to wander at night, the risk assessment advised staff to “monitor regularly” with no other specific guidance. The company’s representative told us that staff use their commonsense when monitoring people at night. An initial assessment for another person alerted staff to the possibility of her choking but no risk assessment had been completed to ensure that measures were in place to reduce the risk of harm. Basic manual handling plans are in place but lack detail about things, which might affect moving people safely, for example where they may be confused. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 15 Concerns were raised by one visiting health professional about bruising found on one person, which was attributed to the improper use of equipment (Refer to standard 38). Once concerns were raised by the health professional alternative equipment was being used. All five staff surveys said the manager “sometimes” gives them clear instructions about the job they are expected to do, suggesting that communication could be improved. The manager has introduced a handover for staff at the beginning of each shift to improve communication. 3 staff surveyed said care plans did not allow enough time for them to provide the care required (refer to standard 27). On the whole existing staff spoken with appeared to have an understanding of people’s basic needs but the lack of consistent information may affect continuity of care when relying on individual staff knowledge. This is particularly relevant when agency staff are working at the home. The manager has complied a summary of people’s needs for agency staff as a quick reference and introduction to individual needs, which is helpful. Daily recordings were generally unhelpful and said things like ‘fine’ today and ‘not very happy’, with no indication of what this really means. Some daily comments/recordings were demeaning. This was discussed with the manager and company representative. We were told that staff had been spoken to about improving the quality of information in daily notes and that only factual information was to be recorded. The majority of people responding with CSCI surveys said they “always” receive the medical support they need, one person told us they “usually” get the medical supported needed and another person said they “sometimes” receive the medical support necessary. Three outside professionals felt that people’s health care needs are “usually” properly monitored and attended to. One wrote, “Staff call the GP for advice appropriately”. One professional said, “Occasionally I have to prompt staff to get assessments completed, for example continence assessments”. The company’s representative felt this was an unfair comment as assessments completed in past had been mislaid by community nurses. The management of people’s health needs was an area of concern as records showed poor monitoring of health needs. For example, care records for two people failed to monitor nutritional needs and weights were not regularly recorded to alert staff to any changes, which may lead to deterioration in people’s health. Weight records looked at indicated that both people had lost a significant amount of weight over a period of two months but no action was recorded in care plans or daily notes about how staff responded to this situation. During the second day of our visit the manager and responsible individual told us that the weights recorded were not accurate and that both people had been weighed again over the weekend. We were told that one The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 16 weight was stable with no weight loss and the other person showed a loss of 2lbs. The relatives of one person felt that their relative had lost weight recently and said that they had noticed their trousers were now too big. One bowel chart showed that the person had not had their bowels open for 17 days. There was no evidence of any action taken to resolve this situation during this time and the care plan had not been reviewed to guide staff about how to address this problem. Records show that people have contact with health services, which include visits from local GPs and the district nursing team, and regular chiropodist visits and the Community Psychiatric Nurse supports some people. The management of people’s medication was looked at; No one living at the home was managing their own medication. Medication administration records showed that variable dose medicines were not accurately recorded with the dose of medicine that had been administered to people. It was not possible to determine from the records made if medicines prescribed for external use, such as creams had been used as prescribed. Two records showed various gaps in the application of creams with no explanation as to why they had not been used as prescribed. There was no information in care plans to guide staff when using “as required” medicines, for example pain control medication or laxatives. There was no system in place to allow staff to determine if the medicine needed to be administered. People spoken with told us that staff are “polite, helpful and kind”. One person said that staff “always” respect her privacy and dignity especially when delivering personal care. Health and social care professionals felt that the care provided “usually” respected people’s privacy and dignity, one wrote, “Staff endeavour to maintain privacy and dignity”. Shared rooms have a portable screen, which provides some privacy and people currently sharing rooms were happy with the arrangements, one person said they “liked the company”. One person described the difficulty they had experienced when sharing a room with someone who had complex care needs and was very restless at night. During our visit most staff were courteous and supportive in their approach to people but it was noticed that one member of staff was rather short with people during the busy lunchtime period, telling one gentleman to sit down in a sharp manner. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. A part-time activities organiser is helping people to enjoy social activities and meals are pleasant and of good quality, however people’s likes and dislikes are not always taken into account. People are not enabled to exercise a full range of choices or take control over their daily lives. EVIDENCE: Surveys received from people living at the home showed that one person felt activities were “always” arranged by the home that they could take part in, four people they could “usually” take part in activities and five people said there was “sometimes” activities they could take part in. When asked about improvements needed at the home, one relative told us, “If something could be done to occupy some of daytime”. An activities organiser has been employed since June 2007 and runs activities/recreational pursuits for three afternoons a week. Another member of staff who was starting the day after the inspection was going to provide activities on the other two days. There was a notice board in the hallway, which showed the programme of activities for the week. These included a memory quiz, bingo and some physical activities. We met with the staff The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 18 member and she explained the different ideas she had with regards to providing activities. These ranged from cooking, trips out, and going out for walks. She said it was important to find out what people at the home would like to do. She also recognised that ‘you can’t force them’. We heard another care assistant reassuring someone that they did not have to attend a quiz if they didn’t want to. The activity co-ordinator had got a book out on the history of Tiverton from the library and was planning on looking at with people at the home that afternoon. She was also keen to make links with a local school, so that children could visit. She said that recent activities had included hand massage and cooking scones. Some people living at the home confirmed this and had enjoyed being able to take part in cooking again. A visitor commented that it would be good if there were enough staff to help out on occasional visits to the town, when someone living at the home needed more than just the visitor to help them in and out of the car. Staff assist one person living at the home is able to visit their spouse twice a week, which is very much appreciated. During our visit and observation period, no activities were organised and there was limited time spent by staff with people apart from when delivering care. During the afternoon at least 10 people were sat in the lounge/dining area and there was a period of 45 minutes without any staff input. Although 56 of this time people were in a positive state of being, meaning they were experiencing more positive than negative feelings, this was mostly one gentleman who was very happily talking to himself and picking things up and fiddling with them. However, with little staff supervision, this in turn caused problems with other people who were telling him to shut up and to stop messing with things. The majority of people observed were in a passive state, meaning there were no observable signs of positive or negative mood. We saw a total of 18 staff interactions during our observation, 15 of which were positive, enhancing people’s experience, these were mainly associated with staff assisting with tasks. The other 3 interactions were neutral; these interactions neither undermine nor enhance people. There was a positive reaction by people when staff walked into the lounge, indicating that staff had developed good relationships with most people. Although some people were seen to move freely around the ground floor, choosing where to sit and who to speak with, others who were totally dependant and sat in their “usual” chairs according to staff. Three people spent long periods of time sitting in their wheelchairs at the dining room tables; one was sleeping with her head on the table. Staff told us they didn’t have the time to transfer everyone into the comfortable chairs in the lounge (also refer to standard 19). One person sat in her wheelchair from the time of our arrival until after 3pm, although she was heard to ask staff if she could go to her room. Although staff said they tried to give people a choice they also told us that there was an expectation that “certain” people would be up early in the The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 19 morning, from 06.00, particularly those people requiring the assistance of two staff. The company’s representative told us that this used to happen but has not occurred since the appointment of the new manager. Care plans did not contain sufficient detail about people’s preferences to ensure that their choices and preference for their daily routine could be consistently met, particularly in relation to those who cannot express themselves clearly. Relatives told us they were always welcome at the home and that staff informed them of any important issues relating to their relative. One relative wrote, “Staff have helped me too”. Two relatives told us that they found the staff “extremely helpful” and one said, “I am extremely pleased with the staff”. Some staff were more skilled than others at ensuring people were offered simple choices, such as what they would prefer at coffee time and where and how they spent their time. One staff member was heard to offer people a choice during lunchtime and was consistently reassuring and engaged people in a positive way, eliciting smiles and other indications of pleasure and wellbeing. Some staff failed to ensure people could exercise choice, for example one staff member told one person to sit down without finding out why they wanted to move. Surveys returned to CSCI showed that nine of the 10 responding “always” like the meals; one person said they sometimes enjoyed the food. People spoken with said the food is of good quality, one person said, “No complaints there” but one or two people found the menus “repetitive and boring” at times. One person said, “It’s always fish on a Friday. I would like a change”. Staff reported that people are offered very little choice and always get same thing for breakfast and same things each week for lunch. The cook felt that menus were working well and she showed a good knowledge of people’s individual dietary needs and likes and dislikes. An alternative dish is available if people do not want the main dish of the day. The menus looked at show that a variety of food is offered to people but several dishes are repeated during the four weekly cycle. The cook makes cakes and puddings daily, which appeared to be enjoyed by people. There are no meals/snacks routinely offered after tea in the late afternoon. Hot drinks and biscuits are offered and the manager told us that anyone could have something to eat if they ask and are hungry. The manager is going to discuss this at the next residents’ meeting and make sure that people are aware they can have sandwiches/snacks if they wish. The AQAA showed that all catering staff had received training in the safe handling of food but records showed and staff confirmed the permanent cook and other staff preparing food required up-dated training (refer to standard 38). The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 20 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 has a good complaints procedure and there are systems in place to ensure that investigations are undertaken, which means that people can be confident that their complaints will be listened to. Unless staff are aware of the adult protection procedures people may not be fully protected from harm or abuse. EVIDENCE: The home has a clear complaints procedure; a copy is on the notice board in hallway for everyone to see. The phone number of the Commission was out of date. Nine of the ten people replying with CSCI surveys knew how to make a complaint but five people said they did not always know who to speak to if they were not happy. Two of the four relatives we contacted said they were aware of how to make a complaint and that the home had responded to concerns or complaints. Two said they couldn’t remember. The AQAA showed that three complaints had been received since the last inspection. One complaint was in relation to poor staff attitude. The complaints log showed people’s concerns were listened to and acted upon. Investigations were undertaken and outcomes were discussed with the complainant. One person told us that they didn’t like to complain but when they raised concerns they were happy with the response. Staff surveys showed that the majority were aware of adult protect procedures; one person said they were not aware of these procedures, which The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 21 could put people at risk. Another member of staff spoken with was not aware of whom to report concerns to outside of the home. Records showed that the most recent member of staff had received training in the protection of vulnerable adults and she showed a good understanding of this subject when we met her. She said that it had made her very aware of her practice. Many other staff were out of date on this training. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 22 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, 22, 24, 25 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People benefit from a clean and homely environment but improvements are needed to ensure people live in a safe home, which meets their individual needs. EVIDENCE: Several improvements have been made to the environment at the home since the last key inspection. The communal sitting room and dining area have been re-painted and new carpets and flooring have been fitted; these areas looked bright and clean. Several people commented on the improvements and said that the home was looking “bright and pleasant” and “It’s lovely”. One person commented, ‘what a different room this is since its been decorated’. People said that disruption had been minimal. Some corridors have also been painted. The dining tables and chairs are old and in need of renewal as support bars are falling off. There are plans to replace these items. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 23 The home is mostly accessible, although the layout is not easy with several corridors and narrow areas. Staff were seen to struggle to manoeuvre larger pieces of equipment needed to assist people to move safely. Staff also reported difficulties when helping people using wheelchairs due to narrow areas and heavy fire doors. No risk assessment had been completed to ensure that practice remained safe. One care manager told us they felt the environment was “restrictive” for people with physical disabilities. There is a passenger lift to access the various floors and the home is equipped with grab rails and ramps in places. Communal space is limited, and all chairs in the lounge were in use. The lounge is also very cramped and the chairs in the corners only accessible by those who are very mobile. The conservatory is used to stored wheelchairs and tables and was cramped and uninviting. There was little room to move people in wheelchairs in the dining room and we saw staff lift the back of one wheelchair to get it round and out. No brakes were put on the wheelchair and the lady then began pushing herself backwards into another lady still at the table. This caused a little disturbance between the two people. The home’s risk assessment for the garden highlights a number of hazards for people including uneven ground, steps and raised drains. The action to be taken to reduce risks is also highlighted but has not been put into action, and the garden presents a “significant risk of falls” according to the risk assessment. The manager said people do not visit the garden without staff to ensure that people remain safe but one person told us that they did go out into the garden alone in fine weather. This was an area of improvement identified by a care manager, who felt that a secure garden would be beneficial to people. Since the last key inspection the home has been awarded a substantial sum by Devon County Council to improve the bathing facilities at the home. As reported previously only one bathroom is suitable to meet the needs of 19 people. Staff told us that four people were now unable to use any bathing facilities at the home so were unable to have a bath. The company director told us that quotes were being obtained for the work, which must be completed by 19 September 2007 as previously required. Some new equipment has been purchased since our last visit to the home in April 2007. A new standaid has been purchased to assist people when mobilising or transferring. Staff told us this had made delivering care much easier. Staff told us there were a limited number of slings to use with this equipment and this meant that people shared slings. This is not ideal and may compromise infection control. During our visit we saw poor manual handling techniques employed by some staff (refer to standard 38). The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 24 Since the last key inspection a considerable amount of work has been undertaken to make the home safe for people. Radiators have been covered to reduce the risk of burning and thermostatic valves have been fitted to most taps to ensure safe water temperatures. The top floor has not been fitted with safety valves to regulate hot water as identified in the home’s risk assessment and this continues to pose a risk to people. During our visit we were joined by an EHO who served an improvement notice to ensure that the home maintains a safe environment for people. Surveys received from people living at the home told us that the home was “always” fresh and clean. Cleaners are employed to ensure that standards are maintained. During our visit the home was generally free from offensive smells and clean. Staff training records show that the majority of staff require formal training to ensure that good practices are established and maintained for infection control – this is conflicting with information provided in the home’s AQAA. The manager has recognised infection control as an area for improvement and has started to monitor practice through ‘spot checks’. Records show that earlier this year the home had an outbreak of a sickness bug. Three people living at the home and three staff being affected. This was discussed with the manager during our visit and she told us that no conclusive source for this outbreak was identified. During our visit we observed several poor infection control procedures/practices, for example poor hand washing by staff and one staff member was seen to sweep up debris from the floor with a dustpan and brush. The dustpan was then placed on top of the clean cloth staff had just put on the table. The manager and staff also told us about other poor practices at the home. The home does not have sluicing facilities and staff are using hand basins in people’s rooms or other sinks in bathrooms for washing/rinsing dirty commode inserts. This practice is not satisfactory and must be reviewed to ensure the good promotion of infection control and general hygiene. Following the inspection, the company’s representative told us that sinks and hand basins are cleaned after this practice. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 25 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. The numbers and skill mix of staff on duty are not always meeting the diverse needs of the people living at this home. Improvements in the home’s recruitment procedure ensure that people living at the home are protected and only suitable staff are employed. EVIDENCE: The manager and one member of staff thought that staffing levels were sufficient to meet the needs of people living at the home. All five staff returning CSCI surveys highlighted staffing levels as an area for improvement. Four staff spoken with during our visit raised concerns about staffing levels, which they felt prevented them from being able to do anything other than the basics. For example staff felt they did not have time to get people out of their wheelchairs, or sit and chat or accompany people out of the home. Staff said that people’s dependency levels had changed and that people needed extra time and attention. The home’s AQAA shows that 18 people require help with washing and bathing and 15 need assistance to dress and use the toilet. The AQAA shows that 7 people need the assistance of two care staff in order to provide the necessary care. This information would suggest that dependency levels were high. During the week the home offers day care to people, usually one person three days a week. Staff are involved in the care of these people too, including providing a bathing service. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 26 Minutes from the last residents meeting held comments made by people about the lack of staff presence at times. Other concerns were raised about the time it took staff to answer call bells. The manager has told people that bells would be answered as quickly as possible and that on occasion all staff on duty may be attending to someone else. People spoken with appreciated this but two described waiting for care and attention at times. Two people told us they felt staff were “always” busy, one person said they “rarely have time to sit and talk”, another said, “I don’t see much of them”. Following the inspection the company representative told us, “We are talking about people who do not always appreciate time and where they think they have been waiting for hours, this may only have been five minutes. Staff are always busy but this may be with care, talking to people, helping at mealtimes”. At night the home has one waking and one sleeping member of staff on duty. One person told us that night staff came when called and were “Very kind and nice to me”. The AQAA indicates that seven people currently require 2 care staff to undertake their care at night. Some staff told us that people’s care needs were not fully met at night, for example people’s continence pads were not changed regularly and some people were often “very wet” in the morning. The company’s representative agreed, “some people are wet in the morning but this is because staff are instructed not to wake residents and disturb them to change pads. People who are awake and wet are changed”. The manager said that the sleeping staff member could be called at any time if assistance was required. There are no records to indicate whether the second carer was called to assist or not. The company representative told us following the inspection that the sleeping carer is “rarely” called. The manager felt that several duties, such as reviewing care plans, weighing people, staff supervision and training were deferred or not fully attended to due to time constraints. Staff spoken with during our visit said morale was low. We spoke to the manager, a director of the company and the company’s representative about staffing levels. In the afternoons there are three care assistants on duty, but they are also responsible for making the afternoon tea and supper and carrying out the laundry duties. The management team felt that staff did not use their time efficiently and suggested that an internal review of staffing levels be undertaken by managers to ensure that staffing levels were adequate. The layout of the building has an impact on staffing levels; it is set over 4 floors, and needs to be considered when judging appropriate levels of staff. The recruitment records of the most recent employee were checked and these showed that all the right checks were in place before she started, which is a positive improvement. Two new members of staff were starting soon, and these records were looked at as well. References had been sent for, and nearly all were received back. Police checks had been sent, and the POVA first checks The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 27 had been returned. Notes of interviews are kept in a notebook rather than peoples own personal files. Over 50 of care staff have achieved a nationally recognised care qualification (NVQ 2 or above) to ensure that staff are competent to meet peoples’ general care needs. Other training is less well addressed. One relative told us, “Some members of staff have been at the home a long time, I think they have the right skills” and one health professional wrote about the “rapid turnover of staff” and felt that this had resulted in some staff “having less experience”. Two of the five staff responding with CSCI surveys said they were expected to care for people outside of their expertise and two said the home did not provide funding or time for relevant training. Staff spoken with reported “little training” opportunities and what was available was not in-depth. A new member of staff had not received a proper induction, and all the printed induction forms for her were blank. Staff have not received recent training on Dementia Care, as this was cancelled due to unforeseen circumstances by the Responsible Individual (the company’s representative). We saw that some staff were more skilled than others when caring for and communicating with people with dementia. People living at the home would benefit if all staff had a good level of knowledge and skills and competencies. Mandatory training is also out of date (refer to standards 26 and 38). The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 28 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 poor. This judgement has been made using available evidence including a visit to this service. People benefit from the manager’s approach, which is open and friendly but she is unable to fully discharge her duties to ensure peoples’ needs are met safely and consistently. There are arrangements in place, which encourage people to be involved in the running of the home, and their views are sought. Not all aspects of health and safety ensure people living at the home and staff are safe and protected. EVIDENCE: The home has been without a registered manager for 10 months. A new manager has been in post during this time but is yet to make an application to register with the Commission. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 29 The manager has good ideas on how to improve the running of the service but does not have enough time to complete them. The manager does not have previous experience of managing a registered care home and currently may not have the qualifications expected. This was discussed with the management team, who are keen to support the manager and provide access to the required training and qualification, NVQ 4 and the Registered Manager’s Award. Funding this course is causing difficulties and as yet a course has not been identified along with a start date. The manager does have six years experience of care home procedures and administration as she was previously employed as an administrator at a registered care home. The home carry out an annual satisfaction questionnaire, which the manager helps people to complete. The home does not currently include relatives, advocates or outside professionals in their review of the quality of care provided. Staff meetings and resident/relative meetings do happen, and there were more planned for July. A different staff member chairs the staff meetings each time, so that staff feel more involved in the process. A visitor said they were aware of relative meetings but didn’t attend. Minutes were seen of the recent meetings, which were detailed and clear. In order to promote good standards the manager has carried out 5 spot checks during July, including night duty. She observes how staff deliver care to people, and makes notes of their practice and any learning points for the staff member. This was seen in a file kept in the office. Although improvements have been achieved since the last key inspection, the home has been unable to meet several requirements within agreed timescales. Records show the responsible individual for the company has not been carrying out monthly-unannounced inspections of the home as required by regulation, which would ensure the service is developed safely and appropriately. The home does not manage peoples’ finances but does administer personal allowances. These are kept safely and access is limited to two or three members of staff. Staff surveys show that staff have not received regular supervision, three staff wrote there was no time for supervision. Nearly all the staff were due to be seen by the manager this month. She then intends to delegate the supervision of the care assistants to the senior care assistants, whilst she will supervise the senior carers. The manager said she is always available for staff to see whenever they want. The home’s management has not ensured that staff have received the necessary training to ensure that people’s needs are safely met. There is a training matrix held in the company’s office next door to the home. This The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 30 showed that many staff are out of date in receiving mandatory training, such as infection control, food hygiene, manual handling and the protection of vulnerable adults. The manager and the responsible individual said this was partly because they put on training events but then no one turns up for them. They intend to write to all staff saying they must attend these training sessions or there would be serious implications for them. Staff surveys showed us that some staff felt there were few opportunities or time for relevant training. Poor manual handling techniques were seen on occasions, which put people living at the home and staff at risk. On one occasion staff employed an outdated ‘lift’ to assist one person. We saw another incident where care staff lacked confidence with equipment and did not use it properly. Although staff had been shown how to use the new standaid, concerns have been raised by one visiting health professional (refer to health and personal care). Accidents appear to be recorded correctly but the manager said she did not have the time to review accidents and incidents in order to identify any trends and put measure in place to reduce the risk of harm to people. Following the inspection, the company’s representative told that all “accidents are investigated at the time of the accident”. Several fire doors have been up-graded since the last key inspection to ensure that they comply with current legislation. Other health and safety matters were looked at and found to be up to date. These included the fire records and electrical wiring certificate. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 31 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 3 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X 1 2 X X 1 1 STAFFING Standard No Score 27 1 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 1 The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 32 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 OP3 Regulation 14 (1) (a) Requirement You must ensure that people’s needs have been assessed by a suitably qualified or suitably trained person. You must ensure that plans of care contain sufficient information about individual’s needs and how these needs are to be met Care plans must be reviewed regularly to accurately reflect people’s changing needs. Where possible, you must consult with people or their representatives when planning and delivering care. (Previous timescale of 30/08/05, 24/02/06, 28/09/06 & 30/05/07 not met) You must ensure that unnecessary risks to the health and safety of people are identified and so far as possible eliminated. Risk assessments must identify behavioural, situational and environmental risks and describe the measures in place to reduce harm. Timescale for action 10/09/07 2. OP7 15 (1) 06/08/07 3. OP7 13 (4)(1) 06/08/07 The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 33 4. OP8 17 (1) (a) Sch 3 3M 5. OP9 13(2) 6. OP18 13 (6) 7. OP19 13 (4) (c) You must keep a record, which includes information relating to each person’s nutritional care needs. You must weigh people regularly and ensure accurate records are kept in order to monitor people’s health needs properly. The application of medicines prescribed for external use must be recorded to ensure that it is possible to audit that these medicines are being used as prescribed. This also applies to the recording of the actual doses administered for those medicines prescribed with a variable dose. (Previous timescale of 30/06/07 not met) You msut make arrangements, by training staff or by other measures, to prevent people being harmed or suffering abuse or being placed at risk of harm or abuse. Appropriate training must to be given to all staff to ensure adult procedures are followed and people are protected. You must implement the actions highlighted in your risk assessment of the garden to ensure people are safe. You must ensure that the bathing facilities at the home are improved in order to meet the personal care needs of all people living at the home. (Previous timescale of 28/12/06 not met) 06/08/07 06/08/07 10/09/08 08/10/07 8. OP21 23 (2) (j) 19/09/07 The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 34 9. OP25 13 (4)(a) You must ensure that water 14/09/07 temperatures are safe in order to reduce the risk of harm to people. This issue has now been passed to Environmental Health for enforcement. (Previous timescale of 8/2/05, 21/12/04, 30/08/05, 26/10/06 & 30/06/07 not met) You must make suitable arrangements to prevent infection and the spread of infection at the home. You must ensure that alternative arrangements are in place for washing and cleaning commodes and that staff maintain good practice at the home. You must ensure that sufficient staff are on duty at all times to meet the needs of the residents and ensure their safety. (Previous timescale of 30/08/05, 10/03/06, 19/09/06 & 30/06/07 not met) You must ensure that all staff are adequately trained to look after people living at the home, with particular regard to those people with dementia. The provider must arrange for a suitable person to visit the home at least monthly in order to monitor and report on the standard of care provided. (Previous timescale of 19/09/06 and 16/05/07 not met) You must ensure that staff working in the kitchen preparing food have received the necessary food hygiene training. (Previous timescale of 30/06/07 not met) 10/09/07 10. OP26 13 (3) 11. OP27 18 (1) (a) 10/09/07 12. OP30 18 (1) 08/10/07 13. OP33 26 (1) (3) & (4) 10/09/07 14. OP38 18 (1) 10/09/07 The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 35 15. OP38 13 (5) 16. OP38 16 (2) (j) You must ensure that suitable arrangements are in place for a safe system for moving and handling people. This includes staff training. You must ensure that safe working practices in relation to infection control are up-held. Staff must have training to help them maintain safe practice. 10/09/07 10/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP2 Good Practice Recommendations It is recommended that contracts be reviewed to reflect current legislation and standards and that all people (where possible) are made aware of the terms and conditions of their stay at the home in order to fully protect their rights. It is recommended that all initial assessments be comprehensively completed prior to the person moving into the home and that assessments are reviewed to ensure that individual needs can be met. It is recommended that the daily notes kept by staff be accurate and respectful. It is recommended that the home continues to develop people’s interests and they are given further opportunities for stimulation through leisure and recreational activities which suit their needs, preferences and capacities; and particular consideration is given to people with a dementia type illness. It is recommended that people’s preferred routine is recorded and that staff ensure choice and autonomy is promoted for less able people. It is recommended that the contact details for the Commission for Social Care Inspection be up-dated on the complaints procedure to ensure that people know how to contact us should they need to. 2. OP3 3. 4. OP7 OP12 5. 6 OP14 OP16 The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 36 7. 8. 9. 10. 11. 12. 13. OP19 OP22 OP29 OP30 OP33 OP36 OP38 It is recommended that you risk assess the use of large pieces of equipment and wheelchairs in narrow corridors to ensure that staff are working as safely as possible. It is recommended that individual slings be obtained for people requiring assistance to mobilise. It is recommended that staff interview notes be kept in their personnel files. It is recommended that all members of staff should receive a structured induction period to ensure they are competent to do their jobs. It is recommended that you include relatives and health and social care professionals in you annual satisfaction survey. It is recommended that all staff receive regular one to one supervision to review aspects of their practice and help to identify any training and development needs. It is recommended that an audit of accidents and incidents be made to help the manager identify any trends and allow her to put measures in place to reduce risks. The Larches DS0000070349.V345402.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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. 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