Inspection on 10/02/06 for The Limes

This inspection was carried out on 10th February 2006.

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

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

Other inspections for this house

The Limes 07/04/09

The Limes 08/04/08

The Limes 08/06/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Limes Glebedale Road Fenton Stoke-on-trent Staffordshire ST4 3AP Lead Inspector Mr Keith Jones Unannounced Inspection 10th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Limes Address Glebedale Road Fenton Stoke-on-trent Staffordshire ST4 3AP 01782 844855 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) Limes Fenton Ltd Miss Justine Gunn Care Home 41 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (15), Learning disability (1), Old age, not falling of places within any other category (41), Physical disability (10) The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two Dementia - DE - Minimum age 55 years on admission. Date of last inspection 24/08/05 Brief Description of the Service: The Limes residential home is located in Fenton, Stoke-on-Trent, close to local facilities and in walking distance of shops and the local library. The Home has been operating for a number of years and was extended in 2003, bringing the number of beds available for residents up to 41. The home has recently come under a new Registered management and continues to provide care for older people within a range of current registration categories including Dementiaover 65 years of age (5), Old age, not falling within any other category (33), Physical disability (4), Physical disability over 65 years of age (10). The accommodation was of a good standard throughout, and provides both single en-suite and double bedrooms. The communal areas included a very pleasant conservatory and a number of lounge/seating areas on both the ground and first floors. The Home had a main dining room and other mixed sitting and dining areas. The car park is situated to the rear of the property and has adequate parking space for staff and visitors. There is a small area of garden to the rear of the property. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day, by one inspector; the deputy care manager and the senior care, in a professional, frank and open manner. The last inspection report was discussed, and it was noted that all outstanding recommendations had been dealt, or were being dealt with satisfactorily. On the day of inspection there were 32 service users in residence. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of service users and members of staff. Service users and staff took an active role in the inspection process and contributed to the subsequent report. Throughout the entire inspection a sense of homeliness and familiar confidence pervaded into all aspects of daily activity expressed by those people met. A sample review of the administrative arrangements confirmed solid practice and effective management. A full verbal report was offered at the end of the inspection. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: What has improved since the last inspection? What they could do better: Further work needs to be invested in completing the task of securing a care planning system that accurately reflects the good standards of observed practice. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 6 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 Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 The resources and services set aside by the home are of a good standard in considering the needs of residents, families and the ability of the home to meet those needs. It is recognised that the Statement of Purpose is to be revised by the new Registered providers of care, although the existing documents represent the foundation on which the home operates upon, offering service users and their relatives the opportunity to make an informed choice about where to live. Residents are admitted to The Limes following a pre-admission needs assessment, always carried out by a senior member of staff. This assessment initiates the process of care, each individual having a plan of care. The registered manager also makes a judgement as to the suitability of each prospective service user using the same criteria. Prospective residents and their relatives are able to visit and assess the quality, facilities and suitability of The Limes at any reasonable time, to meet with staff and management The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 9 EVIDENCE: The Statement of Purpose and service user’s guide continue to represent a good description of the home’s aims and objectives, philosophy of care and terms and conditions, offering service users and their relatives the opportunity to make an informed choice about where to live. All the requirements prescribed in Schedule 1 are addressed. The document is kept under a consistent review to reflect changing circumstances. It is clearly stated in the Statement of Purpose that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of service users. The Statement of Purpose also clearly indicates the terms and conditions, which are discussed with service users and relatives prior to admission. The Inspector was impressed with the attention to detail in recognising the degree of anxiety prospective residents have on moving in to the Home. A pre-admission assessment, always carried out by a senior member of staff appreciated any special needs of the individual including cultural, social or personal needs, which are fully discussed and documented. This assessment initiates the process of care, each individual having a plan of care based on a daily living process. The Home demonstrated through case tracking, that the assessor explained this information in respect of each individual to ensure a clear understanding is established. The registered person also makes a judgement as to the suitability of each prospective service user using the same criteria. At all times the family is kept fully informed of the situation, offering service users and their relatives the opportunity to make an informed choice about where to live. Prospective service users and their relatives are able to visit and assess the quality, facilities and suitability of The Limes at any reasonable time, to meet with staff and management. At all times relatives are involved throughout the process. The home does not admit emergencies. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 The service users’ assessment provides the base from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family. The home has a GP provision that visits the home frequently. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. The Inspector was impressed with the confidence and closeness within the Home of staff, residents and visitors, and the mutual respect that prevailed. The care planning system is presently under a system transfer operation. There exists a straightforward, yet effective medicines administration system, operating in three locations in the Home, all accurately monitored and actioned. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 11 EVIDENCE: Three case records were examined and found to offer a clear, well balanced, up to date and accurate appraisal of requirements. Reviews were done on a minimum of once a month, usually more often, as needs dictate. Case tracking of those three residents confirmed the depth of care planning supported by a solid foundation of organisation and quality services. The system would benefit with a clear daily record of events and daily living. The agreed new format of care planning is being implemented at the time of Inspection. The documentation and appraisal of the system should enhance the good standards that prevail. The home has good links with specialist services – continence advisor and tissue viability. A profile of the service user’s social, physical and psychological status offered an individual plan of care, based upon a model of daily living, to be implemented and frequently reviewed. Each service user’s health, personal and social care needs were seen to be assessed in an individual plan of care that is reviewed monthly, including service users and relatives views, to reflect their changing needs. That review is more frequent, dependant upon the individual’s needs and clinical condition. A tour of the premises evidenced that there was a range of pressure relieving equipment, and examination of service user plans found that all are assessed in relation to pressure sore risk, falls risk and nutritional risk. The administration of medicines adheres to procedures to maximise protection to service users. The storage was secure with satisfactory added security for controlled drugs. Family and friends have relative freedom of visiting, those spoken to remarking on the importance of maintaining social contact. The spiritual needs of service users were recorded and observed by the staff with due respect. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The Limes’ main objective is to respect the individual, thus delivering care in a relaxed and easy environment, with routine flexible to accommodate needs, and not dictate daily life of service users. Personal choice and relative selfdetermination are respected in policy and action. Those who wish to bring in personal possessions are encouraged to do so. These policies are designed to match expectations and to achieve a harmonious relationship throughout. Activities were in evidence on the inspection day and a programme of in-house entertainment was available. Choices were available for every aspect of daily living and menus provided a varied and good choice of food available on a four weekly programme. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. EVIDENCE: The Statement of Purpose and Guide indicate a flexible routine, established to meet the preferences of service users. The policy was evidenced in admission assessment, care plans examined, and talking to service users and relatives, a policy much appreciated and freely expressed. Routine is seen as flexible to acknowledge individuality, yet maintain a focal point for service users to latch on to without dictating events. Staff were observed to hold a friendly, The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 13 sympathetic and confident interaction with service users and family, in lounge areas and at lunchtime in helping those who required assistance. Service users’ life-styles and interests are recorded in their care plans, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. This would be enhanced with the support of a daily report system. The care manager demonstrated the strength of protecting service user’s rights, which was secured through the robustness of the procedures in place. This was confirmed on examination of records. The tour of the Home demonstrated a high degree of expressed individuality in each of the bedrooms inspected. A varied menu is available for service users on a four-week cycle and represent a wholesome, appealing and varied balanced diet. Lunch had been served prior to the inspection and meals were seen to be wholesome and nutritious with service users enthusiastically agreeing on the quality of preparation and serving. Special dietary needs are catered for and monitored as was evidenced through case tracking. Some service users choose to have their meals in their bedrooms. The dining area was pleasant, offering conducive ambience for a social meal. The kitchen was seen to be clean, well organised and with modern equipment. An effective cleaning schedule and food temperature records were not up to date, failing to support the observed good standards, or the recent approval of an environmental health inspection. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place. EVIDENCE: The complaints policy was seen and records examined. There were few complaints, none recent, to assess. All service users had received information on the procedure to complain, including reference to the CSCI. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned The care manager demonstrated satisfactory awareness for a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 15 Case tracking confirmed the effectiveness of providers, care manager and staff sensitive to service users needs and readiness to test the robustness of their information and report structures. Residents’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care, planning and policies in place i.e. the complaints procedure. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 The Home was cleaned to a high standard, homely, and decorated to a very high standard. Individual rooms had been personalized with items of furniture and trinkets. Three rooms were shared, with the remaining rooms having single occupancy. All rooms had en-suite facilities. Communal space included seven sitting and dining areas varying in size. Adequate toilet and bathing facilities were provided with appropriate aids and equipment available to assist manual handling and individual mobility requirements. The Home had adequate heating provided by a mixture of low surface temperature, covered and uncovered radiators. Requirements made at the last inspection had been addressed or were in the process of being addressed. EVIDENCE: The home is well appointed to meet the needs of elderly residential population of service users. The Limes provide a suitable environment to offer a comfortable, discrete yet homely accommodation. All bedrooms are of a suitable size to facilitate a private and personalised living area. Service users The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 17 have virtual free access to safe and comfortable surroundings throughout the home. The home has in place an ongoing redecoration and refurbishment programme, an update of the refurbishment programme for 2006/07 is to be provided for the next inspection. The building complied with local fire service, Environmental Health and Health and Safety requirements. The fire system has been recently updated. Service users have the provision of sufficient and suitable lavatories and washing facilities within the home. The standard and presentation of all the toilets and bathrooms were of a high quality, clean, uncluttered and odourfree. Adequate attention has been given to ensure maximum privacy within risk-assessed boundaries. Each room has adequate space to assist with personal care and dressing assistance, and en-suite. There is a good standard of furnishing complimented with a variety of personal belongings. All personal electrical equipment where seen to be PAT tested. The nurse call system was seen to be effective. Radiators and hot pipe works accessible to service users have been reassessed and a programme of guarding recently completed. Communal areas were pleasantly furnished with facilities to accommodate social or reflective needs, in a homely setting. Several service users spoken to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. Staff are aware of the importance of privacy and the promotion of independence, as noted in discussions and examination of training records. The home presented a clean and pleasant, odour-free atmosphere, much to the credit of staff. To complement the presentation there were numerous floral and decorative displays. Infection control figures highly within the staff induction and supervisory training programmes. Chemical cleaners were used appropriately throughout the home, were seen to be secure and under COSHH recommended practices. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Staffing levels were seen to be satisfactory, the daily care staffing rota showed adequate balance between skills, qualifications and numbers to provide a good standard of care. Staff selection procedural improvements have had a significant effect upon the provision of cares to ensure protection of service users. The home employs a full complement of support staff, including laundry staff and adequate domestic and catering staffing levels. There is a staff induction programme, well established and well designed on which formed the base upon which in-service supervision and training is planned. Formal staff supervision has yet to be formally established, which needs to be extended to encompass general working standards, and be part of the cascaded package involving all the staff. EVIDENCE: Three weeks of off-duty were examined, i.e. 09/02/06 through to 01/03/06. The consecutive duty rotas were examined, providing evidence that the home is managing to maintain numbers, skills and qualifications to ensure the needs of the service users are met. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 19 On the day of inspection the staffing levels were: 07.30 – 17.00 - 1 senior 4 carers 17.00 – 22.00 - 1 senior 3 carers 22.00 – 07.30 - 1 senior 2 carers Agency staff are not utilised, and nurse bank with agreed overtime and flexible rostering meet identified shortfalls, usually holiday time. There is 1 domestic staff 32.5 hours, and 2 laundry staff working a 52.5-hour laundry services. There are 2 catering staff working within 49 hours per week. At the time of inspection there were 8 carers on level II NVQ course, a further 1 in training. The deputy care manager was confident that the home will meet the necessary level of commitment to the training requirements. Documentary evidence confirmed an improvement in the quality of staff selection, recruitment effort and practice. Three staff files were sampled and found to be well organised and up to date, following a review of procedures. There remain some anomalies in lack of consistency of approach. It was evidenced that CRB checks have been made and contracts of employment are up to date. On going personal and training records were kept secure in accordance of the Data Protection Act 1998. Policy clearly states an equal opportunity position. Evidence showed a diligent attention to on-the-job clinical supervised training, involving a shared aspect of responsibility between staff and trainer, with the involvement of mentor trained staff. However there is a continuing need to extend this process by involving general working arrangements to offer a more substantial commitment to the supervision and appraisal process. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The deputy care manager of the home accompanied the inspector on the day. The care manager, although off duty at the time, has demonstrated her capacity as suitably qualified and experienced to manage the day-to-day care of the service users. Mrs Meera Shah and Mr R Patel have been registered as the providers, and are presently consolidating up to date policies, procedures and objectives. The inspector continues to be impressed by the openness and confidence in the observed interactions of staff, relatives and service users. The relationships were seen to be of mutual trust and respect. Evidence was secured to confirm a quality monitoring system has been introduced, based upon audit of standards, care plans and feed back from service users and relatives. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 21 EVIDENCE: The inspector observed at first hand the confident interrelationship that exist, not only between management and staff, but also between staff, service users and relatives. Evidence was secured to confirm that an effective quality monitoring system has been introduced, based upon audit of standards, care plans, general audits and feed back from service users and relatives. Standards are discussed at staff meetings, daily reports, direct observation and involvement and one to one staff meetings. Examination of three staff records showed that employment policies are increasingly effective and meaningful. The procedures manual was randomly examined and found to offer a very comprehensive reference, although these policies are in need of review to reflect changing circumstances and contemporary issues. Regular fire drills and frequent staff training sessions are organised. Records inspected included, fire prevention tests on equipment, six monthly fire training and procedures, Health and Safety checks on equipment servicing, gas servicing, and call alarm maintenance and risk assessments. The accident books for staff and service users were checked and found to be accurate, up to date and Riddor sensitive. These issues and routines ensured the health, safety and welfare of service users and staff. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. The Limes DS0000064713.V285192.R01.S.doc Version 5.1 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 4 4 4 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP38 Regulation 16 2 (g) Requirement That a schedule of cleaning and fridge/freezer temperature recordings be maintained. Care plan review to be completed. You must demonstrate consistency in the recruitment, application and interview procedures within the home. Timescale for action 01/03/06 01/03/06 2 3 OP7 OP29 15.1. 2 (b 19 Sch 2 (5) 01/03/06 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 OP30 Good Practice Recommendations A photograph would enhance the staff file record Staff are to receive 6 sessions of individual supervision during a 12-month period, and these to be documented. A re-furbishment plan be drawn for 2006/07 The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Limes DS0000064713.V285192.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!