Inspection on 24/06/05 for The Old Deanery

This inspection was carried out on 24th June 2005.

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 Old Deanery 03/06/09

The Old Deanery 20/05/07

The Old Deanery 26/01/06

The Old Deanery 17/02/05

The Old Deanery 12/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Old Deanery Deanery Hill Bocking Braintree Essex CM7 5SR Lead Inspector Kay Mehrtens Final Announced 23 June 2005 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 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 Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Old Deanery Address Deanery Hill, Bocking, Braintree, Essex CM7 5SR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01376 328600 Anglia Retirement Homes Limited Clive Ansell-Jones Care Home 70 Category(ies) of Old Age, not falling within any other category registration, with number (70) of places The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 18th February 2005 Brief Description of the Service: The Old Deanery comprises of a large listed building, with a new extension built in August 2000. The home is on two floors and offers single bedroom accommodation, with the exception of one companion room. The majority of bedrooms have en suite facilities. The home offers accommodation to seventy service users who are aged 65 and over. The home is set in large well maintained gardens with an enclosed courtyard provided. Car parking is available and security gates are provided at the entrance to the home. The Old Deanery is situated in the village of Bocking, which is within easy reach of the town of Braintree and surrounding facilities. There is furnished accommodation, for independent living, in a two bed roomed flat on the third floor. Clear criteria are set with regard the tenancy and a separate contract states that tenants access to the home is limited to flat access only, unless invited to visit. Tenants only receive housekeeping provision. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place on the 23rd June 2005, lasting 8.5 hours. The inspection process included: discussions with the manager and deputy, four staff, thirteen residents, three relatives and the registered provider. There were 68 residents accommodated at the time of the inspection. The fees range from £510.00 to £570.00 per week. There are additional charges for hairdressing, newspapers and personal items. The premises were inspected, including the grounds. Samples of records and residents care plans were inspected. The inspection covered twenty-three standards, four of which exceeded the standard. The home was clean and maintained to a very high standard. The staff were caring and had a positive approach to the training opportunities provided. The manager approached the inspection in a positive and cooperative manner that was focused on achieving best practice to meet the needs of the residents. What the service does well: The home provides residents with exceptionally well-presented and maintained premises. The commitment to staff training is ongoing and over 70 of the staff are trained to National Vocational Qualification level 2 or above. Residents are provided with a wide range of activities both in the home and the local community. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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 Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 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 standard(s) 3 and 5 Standard 6 is not applicable. The arrangements for pre-admission assessments are good so staff are aware of residents’ needs prior to their placement. Residents are encouraged to visit before admission and consider the suitability of the home. EVIDENCE: The manager and deputy undertake the pre-admission assessments on all new referrals. The documentation seen was very detailed and covered all aspects of the residents’ care needs and history. It provided a good picture of the person being assessed and enabled them to feel part of the process, as the information is gathered from the prospective resident, their family and other agencies, as appropriate. The assessments provided good information to enable the development of useful initial care plans and consistent care on admission to the home. Several residents and their families informed the inspector that they were able to visit the home prior to admission. The home produces a newsletter that gives information about events and contacts for the home. The home has a The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 9 web site that contains relevant information with regard to the facilities and amenities as well as other information about life in the home. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 The system for residents’ consultation with regard to care plans needs to improve. The health care needs of residents were well met and improvements had been made with regard to medication. The manager and staff are caring and positive in their contact with residents. EVIDENCE: From discussion with residents it was evident that their understanding of care plans was a bit confused, though one relative informed the inspector that information had been requested from their relative and they were aware of a plan of care. However, the manager does need to develop resident input into care planning especially with regard to any changes that may occur for individual residents so that they are more involved in the process. The care plans sampled required more detailed information particularly with regard to the required actions for staff to met the identified needs of individual residents. For example, one plan did not reflect the changes in an activity for one resident or address the dietary needs highlighted by the relatives. The care plans were not consistent in the amount of detail needed to enable new care staff to meet the needs of the residents. The plans were being signed as The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 11 reviewed each month but care plans seen did not reflect any changes following a review. Residents were pleased with the health care provided at the home. They informed the inspector that they see visiting doctors and district nurses in private. They were pleased that staff escorts are provided for hospital appointments, if needed. The manager informed the inspector that the home has developed good links with the local PCT nurse who has provided training and support with regard to residents’ health care needs. This has included training on medication, falls management, nutrition in the elderly and continence advice. The home also uses the support provided by the local Rapid assessment unit and the NHS nurse specialist for diabetes. The staff were observed to respond quickly and effectively during the inspection when a resident suffered a fall. They made sure that the resident was comfortable and reassured them about the health and the treatment that they received. Staff accompanied the resident to hospital and on their return to the home. The inspector had the opportunity to speak to a visiting district nurse. They were generally pleased with the staffs’ response to the health care needs of residents. They did comment on some difficulty that they experienced trying to locate senior staff when they arrived at the home. However, they did feel that this had recently improved. The manager and deputy were aware of this difficulty and informed the inspector that steps were being taken to provide the district nurses with access to the staff mobile communication system, when they arrive at the home, so that they can contact the senior on duty. Records indicated that accidents and incidents were monitored and residents families informed. The storage of medication was well managed. There were good systems in place with regard to controlled medication. Senior staff are trained in the administration and uses of medication by the local pharmacist. Certificates were held on file and the need for refresher training was addressed as appropriate. The issues from the last inspection, with regard to the system for residents taking medication when out of the home, had been addressed. Residents commented positively about the staffs’ attitude towards them. They felt that their dignity and privacy were respected. The inspector observed good practice with regard to staff ensuring residents privacy. For example, they were observed to knock on doors before entering a room and ensured that doors were closed when attending to residents’ personal care needs. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 12 Staff were aware of the individual needs and requests from some residents with regard to their wish to spend time alone in their rooms. Keys are provided for residents to maintain their independence and dignity. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 The home provides opportunities for residents to participate in activities that reflect their wishes. Positive steps are taken to ensure that residents and their visitors are made welcome. Residents are offered a good choice of well prepared and presented food. EVIDENCE: Residents were generally very positive about the variety of activities provided at the home. Activities include armchair aerobics, flower arranging, mobile shop, pat-a dog and various weekly entertainers. The residents certainly enjoyed the entertainer that played the piano and bagpipes for them during the afternoon of the inspection. They felt that their wishes were respected. They enjoyed trips out and the regular entertainment provided, as well as church services. The home produces a regular newsletter that details events and activities. This information is also held on the homes’ web site. Regular resident and relative meetings are held in the home. The large lawns at the rear of the home are regularly used by the local dog training school and so provide residents with a fun source of entertainment. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 14 Relatives and residents were very complementary regarding the hospitality offered whenever they visit. They informed the inspector that they are always made welcome and are encouraged to take meals with their relatives when they visit. There are several lounges for residents to use to entertain visitors in private. The home also offers a menu, with a charge, for residents and families to use for large parties and events, which are generally held in the large, old deanery room on the first floor. Residents were extremely complementary regarding the meals at the home. They particularly liked the large choice of desserts and the offer of a cooked breakfast everyday. The menu is displayed in both dining rooms and offers a good choice of healthy meals. The cook prepares several desserts each day that are displayed on trolleys. The trolley in the larger dining room is able to move to the residents. However, this is not possible with the trolley in the small dining room. The inspector did comment upon this, as it was a lost opportunity for those residents with some confusion, who use this area, to have the chance to more effectively choose their dessert rather than try to remember the list put before them. The manager informed the inspector that this would be looked at. The cook and her staff are to be commended upon their recent achievement of a Gold Food Hygiene award following an inspection by the Environmental Health Officer. The inspection did highlight some concerns regarding the mealtimes in the small dining room. Mealtimes are staggered, with two sittings. The inspector observed the first sitting and participated in the second sitting. There were six residents in the small dining room that required assistance with feeding. The more confused residents mainly occupied this dining room. There were only three members of staff in the dining room. The staff did offer vegetables to residents and pureed meals were well presented. However, the meals for those residents that required help were put in front of them and left until a carer was available to assist. This meant the there food went cold. Whilst the staff did sit to assist residents, some were observed to have little or no interaction with them. This was a missed opportunity for the residents to have one to one time and enjoy a social and pleasant experience. This was not the experience of those residents in the other dining room who benefited from the input of the restaurant service manager and other staff. The staffing ratio was noticeably higher in this area for residents that required less assistance. They did, however, benefit from a pleasant social interaction with staff. This level of service and staff assistance should be the same in both dining areas for each mealtime sitting. Several residents enjoyed their meals in the garden, sitting under parasols, with staff whose care and interaction was a pleasure to observe. The staff interaction and service needs to be consistent so that all residents are treated equally and enjoy the experience. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a good complaints system and there was evidence that complainants are listened to. The manager and staff have a good understanding of the need to protect residents from abuse. EVIDENCE: The home has a good complaints policy and procedures. The complaints record indicates that complaints are addressed and outcomes were satisfactory for those that complained. One complaint is currently under investigation by manager. There was good evidence of staff training with regard to adult protection. Staff have attended training provided by the social services and a senior member of staff is to do a social services trainers day. A video training package on adult protection is also used in the home. The manager was very aware of the need to check the Protection of Vulnerable Adults (POVA) register with regard to staff employment. He is on the county adult protection committee and so very aware of the need for training and vigilance with regard to adult protection. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 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 standard(s) 19 and 26 The staff provide opportunities for residents to participate in activities in the home, that reflect residents wishes EVIDENCE: The home is decorated, furnished and fitted to a very high standard. The provider has nearly completed a redecoration programme of the home. Residents are encouraged to bring their own possessions. Residents and relatives informed the inspector that they thought the premises were really lovely and extremely well decorated. The residents enjoy the use of the large conservatory. The other communal rooms offer them the choice of where to entertain guests as well as provided them with a quiet, solitary space, if needed. The home also provides the residents with a large enclosed courtyard that has recently been covered with “Astroturf” to ensure that safety of residents in wet The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 17 conditions. The courtyard has ample seating and tables and the activity worker hopes to encourage residents to use the “grass” area for a game of bowls. The gardens are large and extremely well maintained. There is a footpath circling the grounds that is suitable for wheelchairs. This was much appreciated by visitors as it enabled them to “walk” their relatives when they visit in good weather. The gardens, at the rear of the home, also contain a large, scented garden area with a footpath. This too is much appreciated by residents and visitors. The gardens provide the residents with different sitting areas. There is ample sturdy garden furniture and a brick and timber built gazebo for the residents to access. The residents and their visitors were using these facilities during the inspection, as it was a lovely sunny day. The staff ensured that everyone had access to shade through the provision of several large parasols. The residents were very complimentary regarding the garden and the home. The home is clean and free from any offensive odour. The laundry was well organised. Residents and their families were pleased with the laundry service. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Staffing levels and the high level of training ensure that the needs of the residents are well met. Staff are recruited after a thorough recruitment process. EVIDENCE: Examination of the staff rota and observation during the inspection indicated that the manager and deputy are on duty until 5pm. The home has two floors. One senior and three care staff are allocated to cover each floor with four waking night staff to cover the night shift. Additional staff are provided to escort residents to health appointments where needed. The home employs two activity workers throughout the week and a restaurant services manager and housekeeper. Appropriate levels of domestic, administration, gardening, maintenance and catering staff are employed in the home. The staffing levels are sufficient to meet the needs of the residents. However, staff breaks and task allocation needs to be better managed to ensure that there are sufficient staff available to assist residents at busy times, especially mealtimes. During the lunchtime meal, in the small dining room, the inspector observed six residents that required assistance. However, there were only three staff in the room to assist. The manager did inform the inspector that the two activity workers should have been available but were called out for a meeting. However, the inspector noted three members of staff outside, in the staff area, having their break. Whilst it is acknowledged that staff require rest breaks, it is questionable whether the first lunch sitting, for a large amount of The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 19 residents, many of which needed help and others that would benefit from conversation, is the most appropriate time for staff to be absent. The second lunch sitting had noticeably fewer residents and a higher staff ratio. The manager and deputy need to address this imbalance and meet the needs of all the residents. The home has recently employed some overseas staff. The inspector received differing comments from residents with regard to their level of English and understanding. However, the inspector did meet one of these carers and was impressed by her keenness to learn and her current ability to speak and understand English. Residents were very positive regarding their helpfulness and caring attitude. The inspector observed good practice in their handling of a distressed resident. They sat with the resident and tried to reassure them in a gentle and respectful manner. Other staff spoken to, at the inspection, were aware of the individual needs of the residents that they were assisting. They were observed to be very gentle and respectful when meeting the health and physical care needs of the residents. Residents were very complimentary regarding the staff at the home. Several told the inspector that the staff were friendly, chatty, respectful and helpful. One resident wished to be quoted as saying, “you won’t find a better home, anywhere!” Relatives, too, were complimentary, stating that the staff always made them welcome. Staff recruitment records were well managed and all required checks and information, on staff files sampled, were in place. The commitment by the provider and manager to staff training is excellent. The home has over 70 of staff qualified to National Vocational Qualification level 2 or above. Several members of staff have also achieved NVQ in customer services and all the domestic staff have NVQ in housekeeping. Records and certificates indicated a high level of staff training on many topics relevant to the needs of the residents. This included the topics mentioned previously in this report with regard to health needs, such as medication, diabetes and care of the elderly and adult protection training. The domestic staff have received training with regard to health and safety (COSHH). The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35, 37 and 38 The manager is well supported by the owner and staff in providing a well managed home that ensures good care for the residents. Records were well maintained and ensured the safety of residents and staff. EVIDENCE: The Old Deanery is a well managed home. The manager is well qualified and has a good senior team. The provider is very supportive and this is evident in the commitment to staff training and the high standard of the premises. Both the manager and provider are well known to the residents and relatives thorough their regular presence in the home. Residents spoke very highly of the manager and the staff team. New staff felt well supported by the manager and senior staff and positive about the training opportunities. Residents’ financial records and affairs are well managed by the homes’ administrator. The office staff are aware of those residents under power of The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 21 attorney and ensure that relatives are made aware of any purchases or requests from residents. Several residents manage their own finances and are provided with lockable facilities in their rooms as well as a key to their door. Health and safety records were well organised. The required checks with regard to electrics, gas and water temperatures are maintained and monitored. The inspector did notice a small area outside the main entrance that required resurfacing, as it could be hazardous to residents and visitors using this area of the home. Records, with regard to fire drills, highlighted the need for more regular drills for the night staff and for all staff to sign the record when completing a fire drill. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 4 x x x x x x 4 STAFFING Standard No Score 27 2 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x 3 x 3 2 The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 23 No Are there any outstanding requirements from the last inspection? 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 38 Regulation 23 Requirement The registered person must ensure that all staff, particularly night staff, participate in regular fire drills and that records evidence their attendance. The registered person must ensure that all areas of home and grounds are safe. This refers specifically to the rough surface area outside the main entrance to the home. Timescale for action 07.08.05 2. 38 23 07.08.05 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 1 Good Practice Recommendations The registered person should include the views of service users, regarding the home and care provided, in the Service Users Guide. This was raised at the last inspection and will be monitored at the next inspection when the results of residents/stakeholder surveys are completed. The registered person should ensure that residents food is served hot and that sufficient staff are available to assist those residents that require help. The registered peson should ensure that the level of I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 24 2. 3. 15 15 The Old Deanery 4. 27 service and staff assistance is the same in both dining areas for each mealtime sitting. The registered person should ensure that sufficient staff are allocated to tasks to meet the needs of the residents. This refers specifically to the lunchtime arrangements. The Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Fairfax House Causton Road Colchester Essex C01 1RJ 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 Old Deanery I56-I05 The Old Deanery S17972 V222339 AI 230605 Stage 4.doc Version 1.30 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. 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