Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 21/11/06 for The Limes Nursing Home

Also see our care home review for The Limes Nursing Home for more information

This inspection was carried out on 21st November 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

What the care home could do better:

The home has to carry out certain checks on their staff before they start working to make sure they are safe. This includes Criminal Records Bureau (CRB) checks, which must be carried out for all staff, and a record kept detailing when the check was received, and the certificate number. This was not being done well and the management and owner must make sure these checks are always done. Staff records must be updated, to include training and development needs; supervision and appraisals. All staff must receive training in the Protection of Vulnerable Adults to ensure residents are safeguarded from all forms of abuse. Service user views must be gathered through a quality assurance system to make sure the home is meeting the identified needs of residents. Service users must be provided with a Service User Guide detailing the support and facilities to be provided by the home, and contract details.

CARE HOMES FOR OLDER PEOPLE The Limes Nursing Home 816 Wilmslow Road Didsbury Manchester M20 2RN Lead Inspector Sue Henstock Unannounced Inspection 21st November 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Limes Nursing Home DS0000021648.V320344.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 Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Nursing Home Address 816 Wilmslow Road Didsbury Manchester M20 2RN 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) 0161 446 2141 0161 445 9524 Britannia Care Homes Limited Mrs Ntswaki Elizabeth Moiloa Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (1) of places The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users requiring nursing care shall be 41. The maximum number of service users requiring personal care only shall be 1. Minimum nursing staffing levels as set out in the Notice issued under Section 13(5) of the Care Standards Act on 15 May 2002 must be maintained. One named service user currently accommodated to receive nursing care is under pensionable age. Should this service user no longer require the accommodation offered by The Limes the service user category will revert to OP (old age). 18th April 2006 Date of last inspection Brief Description of the Service: The Limes Nursing Home is a care home providing nursing care for 41 older people and personal care for 1 older person. The Limes Nursing Home is formed around an adapted and refurbished Victorian house with a modern extension set in its own grounds. The home previously had two distinct areas, one providing continuing care and the other intermediary care. The home no longer provides intermediary care. The home provides 42 beds and is used for residents admitted for continuing care. Accommodation is on 4 floors all of which have lift access and are wheelchair accessible. Facilities within in the home are located in two separate wings, each with a communal lounge and dining area. The kitchen and administration office is located on the lower ground floor, next to one of the dining rooms. There is a central office and separate staff room located at the main entrance to the home, which is central to the two wings. There are two treatment rooms, located in each of the two wings. In one wing there is a large lounge on the ground floor, which gives access to an enclosed conservatory providing a bright, airy view of the grounds of the home. There is a dining room on the lower ground floor. The second lounge has a French window that gives direct access to the garden and has a small dining area. There is a small kitchen next to the lounge where visitors and staff are able to make light refreshments. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 5 There are 20 single bedrooms, and 11 double rooms with en suite facilities. At the time of the inspection visit there were a number of vacancies as the contract for intermediary care had ended. The gardens are laid to lawn, and well maintained with sufficient car parking available for visitors and staff. The home is located within a short walking distance of Didsbury village and all its amenities. There are two local parks within short walking distance from the home. Bus stops to Manchester and surrounding areas are within 100 yards of the home. The home’s fees for residents vary from £365 to £610 weekly. Charges for hairdressing, newspapers and chiropody are extra, but are invoiced following supply. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The report provides information on the Limes Nursing Home gathered since the last inspection, 18 April 2006. The site inspection was unannounced. The key site inspection, which forms part of the inspection process, took place at the home on Tuesday 21 November 2006, starting at 9.00 am and finishing at 5.15 pm. The Registered Manager and the Proprietor (Responsible Individual) were on duty at the time of the inspection visit. The opportunity was taken throughout the visit to speak to residents and staff. A tour of the building was carried out and records inspected. User comments questionnaires were left at the home but none had been returned at the time of report writing. What the service does well: What has improved since the last inspection? The care plans inspected were all in order, containing details of nursing and risk assessments, and care plans. Most of the bedrooms and communal areas have recently been decorated and new storage units have been purchased for bedrooms, which will provide, when installed, lockable facilities for personal valuables. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 7 A visiting physiotherapist organises activities twice a week at the home and residents said they enjoyed them – ‘they are good for you and keep you fit’. One session took place during the inspection, and residents were encouraged to take part. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a Statement of Purpose, detailing its’ aims and objectives. There was no Service User Guide available. The home was able to meet the assessed needs of residents. Staff had the necessary skills and ability to care for residents. EVIDENCE: A Statement of Purpose detailed the aims and objectives of the home, however there was no Service User Guide available or details in individual resident files. The evidence suggested, and the manager confirmed, that residents have a needs assessment carried out before admission to the home, involving the manager and referring agencies. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 10 The case files reviewed all contained detailed nursing assessments, including risk assessments, with up to date daily records, which were signed and dated. However, there were no details relating to the residents’ life history. Assessments were carried out by the manager, referring agency, and the funded nursing team at the local Primary Care Trust (PCT), to ensure the home could meet the needs of residents. Prospective residents and their relatives could visit the home before admission. All of the residents required a great deal of physical care and assistance including the use of wheel chairs, hoists and help with eating and the home had appropriate equipment to meet residents’ needs. At the time of the inspection visit there were a number of vacancies, following the end of a contract for intermediary care. The proprietor had sent information about the home to referral teams and was considering ways of filling the vacancies. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed nursing assessment and care plans ensured residents’ needs were met. Residents’ dignity and privacy were respected by staff. EVIDENCE: All files inspected had nursing assessments and care plans. Plans included risk assessments, and details of their medical conditions and requirements. Medication records, storage and administration were all in order, with appropriate policies and procedures in place. Each nurse was responsible for 4 – 5 residents, who were responsible for ensuring individual needs were met and that residents are treated with dignity and respect. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 12 The care plans were medically focused. Residents had appropriate risk assessments, reviewed monthly. Medication records, storage and stocks, including controlled medication, were all in order, with good written records. There were two treatment rooms, with appropriate storage and signage, both of which were kept locked at all times, with the Nurse in Charge holding the keys. The home did not manage any resident monies and residents and relatives are advised of this. If residents need to purchase anything, e.g. hairdressing services, the home paid the bill and then invoiced their account. Staff were observed to treat residents with respect. However, as many staff wre from overseas (India primarily) there were issues of language and communication difficulties, particularly for residents with hearing difficulties. The home had organised a staff training course on ‘English as a second language’ from the local college, which should be repeated on a regular basis. The manager supervised staff as they carried out their duties and provided information, advice and where appropriate instruction to staff to ensure they were meeting the individual needs of residents. Residents stated that they liked living in the home, the food was good, they had no complaints, visitors could come at any time and they described staff as ’nice and helpful’. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Organised activities were provided for residents, which they could choose to attend. An open visiting policy enabled residents to maintain links and relationships with their families. Meals provided a balanced diet and individual dietary needs were catered for. EVIDENCE: There were planned activities organised by the visiting physiotherapist, which residents were encouraged to take part in. The physiotherapist visited during the inspection – she attended twice a week (Tuesday & Saturday) to provide organised activities such as exercise classes, music sessions, arts and crafts. During the inspection she ran an exercise class for residents who wanted to attend. They all seemed to enjoy it and commented later that it was ‘fun, good for you and keeps you fit’. Details of forthcoming events were displayed for residents and their visitors. Residents said they liked watching TV, and talking to one another and enjoyed having visitors. There were no planned activities documented or preferences The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 14 identified in individual files. The only planned activities were those by the physiotherapist. Many of the residents were in the 80s and 90s and spent their time watching TV, chatting or dozing. Many residents suffered from dementia and seeking their views on activities and how the home provided services was difficult. Some residents received visitors from their local church and took part in religious services. There was a three week menu which provides a balanced diet – residents said the food was good, and there was a choice. Dietary needs were catered for. The Proprietor stated that refreshments were available in between meal times, and there was a small kitchen where families and visitors could make drinks. Facilities were available for visitors to make refreshments and staff would respond to request for refreshments. There was evidence of relatives of an Asian residents bringing Asian food in, and facilities were available for them to reheat the food. Residents could bring personal items to the home for their private bedrooms, including furniture if requested. There was an open visiting policy for family and friends and the manager and proprietor made time to speak to relatives when they visited. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were policies and procedures for the protection of adults in place. The home must make arrangements for all staff to attend training in the protection of vulnerable adults. EVIDENCE: The home had a complaints procedure, which was available to residents and visitors. A copy of the complaints procedure was displayed in the front entrance to the home. The manager stated no written complaints had been received in the home although the Proprietor confirmed two complaints had been received via the Commission for Social Care Inspection (CSCI), which he had dealt with in line with their complaints policy. These were investigated and appropriate responses sent to the complainants and CSCI. The manager gave examples of concerns or complaints raised by relatives, such as items of relatives clothing not available. She stated that if a resident had a complaint they could put it in writing or tell staff verbally. The manager and proprietor would investigate and if the resident was still unhappy they would be advised to send their complaint to CSCI. Residents and visitors to the home understand how to make a complaint and there was a clear investigation process. Residents stated they were happy in The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 16 the home and knew who to talk to about any concerns. However, many residents were unable to give their views, due to their medical condition. Residents said they had no complaints and if they had any concerns they would talk to matron (registered manager) or the owner (proprietor) or the nurses. The Manager had provided information to staff to raise their awareness of issues in the protection of vulnerable adults. The manager was very clear about what constituted abuse, and gave examples of more subtle forms of abuse. Since the last inspection she had copied the policy and procedure from their policy file and distributed it to staff, which they then discussed in a meeting. The manager and proprietor were advised that in addition to on-going internal staff awareness training, arrangements must be made for all staff to attend training in the protection of vulnerable adults. The proprietor has recently obtained details of external training courses and would pursue this. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained and provided a safe, pleasant environment for residents. EVIDENCE: The home was well maintained, clean and odour free. There was evidence of redecoration of bedrooms. A cyclical redecoration and maintenance programme ensured the home was clean, safe, and free from unpleasant odours. The proprietor arranges for vacant bedrooms to be redecorated before new residents move in. Individual bedrooms appeared to be comfortable, light and airy with personal possessions evident and residents are able to bring in their own furniture if they wish -one resident has brought her bed with her. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 18 There is a large conservatory attached to a communal sitting room, which provided additional communal facilities for residents and their visitors. The proprietor had purchased new storage units for the bedrooms, which will be lockable – the units have been delivered but were still to be assembled. The Statement of Purpose detailed the fact that bedroom doors do not have locks unless specifically requested by residents. The proprietor stated that this had been discussed with residents. He was advised to include a statement, to this effect, in a Service User Guide, which must be produced and given to residents. All areas of the home were clean, tidy, with appropriate storage space. The laundry room had individual baskets for each resident’s clothes. The manager stated there had been no problems relating to infection control. There are two lifts in the home, which are serviced monthly- they were serviced during the inspection. The home employed a maintenance man who undertakes weekly and monthly maintenance checks - records were up to date, signed and dated. A maintenance logbook detailed all work undertaken in the home. The home has a large conservatory attached to one of the communal sitting rooms. The gardens are attractive and well maintained and residents made use of the garden in good weather. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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 home was staffed with appropriately qualified nursing staff, however the recruitment system did not fully protect residents. EVIDENCE: The service had recruited most of its staff from overseas. Files contained relevant documentation relating to their qualifications, references, work permits and police clearance certificates from their country of origin but CRB checks were not available for all staff, which must be a priority for the home. POVA first checks were available for some staff. The home had provided external training in English as a second language, which should be repeated to improve communication between residents and their visitors and nurses from overseas. The proprietor carried out telephone interviews to check their use and understanding of English, and their experience. There was no documented evidence of the telephone interviews. The proprietor was advised all interviews should be recorded and details kept in the individual staff member’s file. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 20 Only one of the files inspected contained a CRB certificate – the proprietor was advised that CRB certificates over 6 months old should be destroyed, once they have been verified during a regulatory inspection. A record of all CRB checks, detailing date received, certificate number, and date verified by an inspection, should be retained by the home. An Employee handbook detailed all issues relating to terms and conditions of employment, and policies relating to disciplinary, grievances, appraisals, safety, staff welfare, and termination. A staff supervision system, providing regular 1:1 supervision needs to be developed, with a clear process for identifying individual training and development needs. There were sufficient numbers of appropriately qualified and experienced staff, able to meet the needs of residents. There was always qualified staff on duty. Some of the staff who are employed as ‘carers’ are also qualified nurses, who have undertaken ‘Adaptation Training’ and who are waiting for qualified positions. There had been a reduction in the number of staff as the home is no longer providing intermediary care and the current number of residents was 28 (capacity 42). There were no records of training and development plans, supervision notes or appraisals. The home’s Statement of Purpose states appraisals would be undertaken 6 monthly but there is currently no system in place. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was managed by an experienced registered nurse. The homes policies and procedures and regular equipment and maintenance servicing and inspections provided a safe environment for residents to live in. EVIDENCE: The homes’ Statement of Purpose sets out the aims and objectives of the home but the absence of a Service User Guide and formal system to monitor user satisfaction means there was no evidence that service users views were taken into account in the running of the service. The manager stated she talked to relatives and residents informally, on a regular basis and discussed The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 22 any issues, or concerns they had. The proprietor spent five days each week in the home and was readily accessible to residents and visitors. There was an open policy for visitors, and weekends were particularly busy. There was evidence of facilities for visitors to bring different food/meals in for their relatives, for example, Asian food. The home does not manage residents’ monies, and residents and relatives were informed of this prior to admission. The home kept a small amount of money on the premises, managed by the administrator for day to day items. Policies and procedures had been developed from the Registered Nursing Home Policy & Procedure Manual (Blue Excellence).There was a comprehensive list of policies at the front of the file. The Manager discusses policies in procedures in handovers and staff meetings, although these were held infrequently and there was no record of meetings. The policy file was easily accessible, and some policies had been copied into a separate ‘training file’. The manager also draws staff attention to important issues by memos, which were displayed in the front office. There was no formal supervision system in place, although the manager stated she supervised staff all the time whilst they were performing their duties, and she was able to provide immediate feedback, and instruction where necessary. The manager received support from the proprietor who was on site 5 days per week, but she does not receive regular 1:1 supervision or appraisal. The home had maintenance and service agreements in place for facilities and equipment, and records were in order, and all weekly checks were up to date, ensuring a safe environment for residents. The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 2 X The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 24 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 OP29 Regulation 9, Schedule 2 (7) 5 18 24 Requirement Timescale for action 20/12/06 2. 3. 4. OP1 OP18 OP33 The proprietor must make sure that CRB checks out for all staff as detailed in schedule 2 of the Care Home Regulations. The Service User Guide must be 16/01/07 updated and copies given to residents All staff, including the manager, 13/03/07 must attend training in safeguarding vulnerable adults The home must develop a quality 13/02/07 assurance system and monitoring tool to seek the views of residents and visitors. 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 OP36 Good Practice Recommendations A staff supervision system needs to be developed and implemented, to ensure staff receive regular 1:1, documented supervision and periodic performance appraisals. DS0000021648.V320344.R01.S.doc Version 5.2 Page 25 The Limes Nursing Home Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Limes Nursing Home DS0000021648.V320344.R01.S.doc Version 5.2 Page 26 - 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!