Inspection on 31/01/07 for The Old Library

This inspection was carried out on 31st January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Old Library 22/01/09

The Old Library 09/01/08

The Old Library 01/02/06

The Old Library 22/06/05

The Old Library 10/03/05

The Old Library 16/08/04

The Old Library 26/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Old Library Isaac`s Hill Cleethorpes North East Lincs DN35 8JR Lead Inspector Mrs Kate Emmerson Key Unannounced Inspection 31st January 2007 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 Old Library DS0000002908.V329560.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 Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Library Address Isaac`s Hill Cleethorpes North East Lincs DN35 8JR 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) 01472 601364 Mr Charles William Jackson Position Vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: The Old library is a 30-bedded care home registered for older people. The accommodation is set in a Victorian style building, retaining much of its original features. It is set in the seaside town of Cleethorpes, with views of the main thoroughfare to the sea front. The homes ownership has remained stable for a number of years and many staff have been retained by the home, which has given a great deal of stability to the service users. The current acting manager has yet to be approved by the CSCI. There are eighteen single rooms and six shared rooms; one of the shared rooms has en-suite facilities. The home has two lounges and an adjoining dining area; all rooms are decorated and furnished to a good standard. There are bathroom and WC facilities located on each floor. The home has equipped itself with a variety of aids to accommodate the dependency of the service users in the home. The fees for the home are £329 per week. Additional charges include chiropody £9.00, hairdresser £5.00 – £23.00. The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in January 2007. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spoke staff working in the home at the time of the inspection and people who lived in the home. Surveys were also received from six care staff and eleven service users. Some of the records kept in the home were checked. This was to see how the people who lived in the home were being cared for, that staff were safe to work in the home, that they had been trained to their job safely and to make sure that the home and the things used in it were safe and were checked regularly. The home was checked to see if it was kept clean and tidy. The home provided a very friendly atmosphere and the service users expressed satisfaction with the care provided. The manager had been in post for the past six months and the majority of requirements form the previous inspection had been met. What the service does well: The manager visited residents before they arrived at the home to see if their needs could be met and then a care plan was developed so the staff knew what care the person needed. The home had made sure that when they have identified that a resident may be at risk they write and carry out a plan of care to reduce the risk. The residents had the opportunity to read and discuss their care plan and had signed to evidence this. The home provided very comfortable and clean and tidy accommodation. The manager made sure that the health and safety of the residents and staff were protected through staff training and procedures in the home. Care plans had been updated. The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 6 The manager had now clearly shown how the decisions regarding the number of staff on duty in the home were made and shown that there were enough staff to meet residents needs. What has improved since the last inspection? What they could do better: They must make sure that the care plans are more specific about the care people need and they must look at care plans in more detail on a regular monthly basis to check that the care plan is still relevant. The must check regularly that the service users have not lost/gained too much weight so that their health is maintained. They must make sure that the medication kept in the fridge securely stored. They must investigate all complaints fully to ensure all issues are addressed. They must ensure that staff receive training in the protection of vulnerable adults and associated policies and procedures so that they are able to recognise abuse and report any suspicions appropriately. They must ensure that they must control odours in bedrooms. They must make sure that new staff have a thorough induction to the home so they know the policies and procedures and the standards expected of them. They must let the service users know the results of the quality review and any surveys undertaken in the home. They must make sure that service users are not put at risk by ensuring fire doors are not wedged open. The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 7 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 Old Library DS0000002908.V329560.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 Old Library DS0000002908.V329560.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 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided clear information about the services provided in the home and ensured that service users needs could be met prior to admission. Information provided required some slight updating. EVIDENCE: There was detailed information about the service provided in the home in the form of a service users guide and a statement of purpose. This was made available to service users and was sent to prospective service users on enquiry. The information required updating in respect of the management changes in the home. Service users stated in surveys that they had received adequate information about the home before they moved in. The majority stated that they had received a contract/statement of terms and conditions The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 10 and there was signed evidence in individual’s files of agreement to the contract/statement of terms and conditions. The home offered a trail period and service users were encouraged to have a short visit to the home for a meal before they decided to stay in the home. A preadmission assessment of the service users needs was completed by one of the management team and this was signed and agreed by the service user. The home had completed a recent audit of the processes in the home and from this they had implemented a new policy and procedure to improve the admission process for service users. The home ensured that a care plan was completed for the service user prior to arrival and a staff member was assigned to meet the service user on arrival to the home. The Old Library DS0000002908.V329560.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 adequate. This judgement has been made using available evidence including a visit to this service. Generally there were detailed care programmes in place to support the care that was given in the home. A lack of consistency in application and detailed and regular evaluation of care plans may put service users health and welfare at risk. The service users were enabled to self-administer medication and the homes policies and procedures supported safe handling of medication. Refrigerated medications were not secure. The service users felt they were treated with respect and privacy was upheld. EVIDENCE: Random selections of care plans were examined. The care programmes were generally detailed. There was evidence in the programmes that individual risk The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 12 assessment was undertaken; risk assessments for moving/ handling, tissue viability, falls, nutrition, bed rails and general issues were in place. Daily diary records were well maintained and detailed. There was evidence that service users health was monitored and professional advice sought for pressure area care and dietary needs. There was evidence in some cases of weekly evaluations and regular reviews. There was evidence that care plans had been discussed with the service users and they had signed to agree them. The deficiencies in the care plans were mainly due to a lack of consistency in care planning and the way these were developed and evaluated and the formats used. Care plans sometimes lacked direction in terms of specific care needs for example how often a service user needed to be weighed or reporting details/incidence re challenging behaviour. Service user had not always been weighed as directed in care plans. Evaluations of the care plan had not been completed monthly in all cases and records in this area lacked detail and did not always cross reference to other areas such as weight loss/gain and risk assessments/action plans were not always evaluated. The evaluations of the care plans had not been completed when the key worker was off sick. Reviews had not been completed consistently and updates tot the care plans were not consistently dated and signed by the staff making the changes. The home had well developed procedures in place for the safe handling of medication, which included self-administration of medication and accredited training for the staff responsible for handling medication. Records were clearly maintained. There were no controlled drugs prescribed or stored in the home at the time of the inspection. A lockable box had been purchased for medication to be held in the refrigerator but as the box was not fixed in the refrigerator this was not secure. One service user was self-medicating and a risk assessment had been completed for this. The service users felt they were treated with respect by the staff and their privacy was respected. The induction programme covered service users rights to privacy and dignity. To encourage service users privacy and dignity to be respected terms of address were indicated on the care programmes, a telephone was available for service users to use in private, service users personal mail was handed directly and unopened to the service user, unless otherwise agreed and privacy locks had been provided on the service users private accommodation. Observation of staff during the inspection identified that they were patient and courteous at all times. The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 13 The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 14 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. Service users felt they were able to exercise control and choice over their lives. They enjoyed the activities and meals provided. EVIDENCE: The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 15 The home had a policy on choice and advocacy in place. Service users spoken to felt they were able to make choices about their daily routines and activities within the home. There was evidence that people had been encouraged to personalise their rooms. In the reception area there was information on advocacy services and solicitors and how to access records. There was also information regarding planned activities and how to make a complaint. The homes management was proactive in ensuring that service users were enabled to maintain contact with their local community and peers and had joined a local group of care homes to provide joint activities. The service users generally enjoyed the activities available to them. The meals were provided on a four-week rotating menu. The cook spoken with was able to describe service users individual dietary needs and records were maintained to support this. Records of food served were held. Service users generally enjoyed the meals provided and comments received included ‘the meals are good’, ‘good choices’, and ‘very good’. The home had completed a recent service user audit of the meals, which showed high levels of satisfaction. Most of the staff that responded to surveys thought the food could be improved in terms of more choices at meal times. The meals were observed on the day of the inspection and were generally well presented with different portion sizes. There was one main meal on offer at lunchtime but an alternative would be made available if requested. The service users liquidised /soft diet was presented all mixed together, this does not enable the staff to offer different elements of the meal separately to service users so that they may enjoy the different tastes and textures. The kitchen was very clean and tidy and all associated records for the safe handling of food were maintained. The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users were aware of the complaints procedure but due to poor investigations of complaints issues were not always fully addressed. Not all staff had received training in the protection of vulnerable adults, which may put service users at risk of abuse not being recognised and acted on appropriately. EVIDENCE: The service users indicated in the surveys that they knew who to speak to if they were not happy and knew how to make a complaint. The home had a reasonable policy and procedure for management of complaints. The records of the five complaints received by the home since the last inspection was examined. In two cases there was little evidence of investigation into the complaints and the home had just generally accepted the complaints. Due to the lack of investigation the home had failed, in one instance, to address the issues fully leading to a complaint to the Commission and the Protection of vulnerable Adults (POVA) team. The complaint was The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 17 under investigation by the Local Authorities POVA team at the time of the inspection. The staff had access to a copy of the multi agency policy and procedures on protection of vulnerable adults; there was also a detailed homes adult abuse policy, which linked in with this document. There were policies on restraint, dealing with aggression, whistle blowing and managing service users finances in place. There was provision of protection of vulnerable adult training but not all the staff had accessed this. The manager stated that training was given to new staff within induction and on an ongoing basis. Of the four staff files seen none had fully completed the induction process but two had completed additional training in protection of vulnerable adults. Staff displayed variable knowledge of protection of vulnerable adults and whistle blowing in surveys. The improved recruitment procedures in the home offered protection to the service users. The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided a very comfortable and homely environment. It was generally clean and tidy and well maintained but odour was not well controlled in some areas. The home and gardens were accessible to all the service users accommodated. EVIDENCE: The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 19 The home was located in a very central area, close all the local amenities and sea front. The home had three floors that were accessed via stairs or passenger lift. The general condition of the furnishings and decoration was of a good standard; redecoration and refurbishment was ongoing. There was one blind in a bedroom which was torn at the edge and records showed replacement of this had been outstanding for some time. All areas seen as part of this inspection were clean and tidy, including the grounds. There were four bedrooms that were odorous. A letter provided by the proprietor indicated that the water system in the home was a pressurised system and hot water was not stored, minimising the risk of Legionella. The bathrooms hot water temperatures were within acceptable limits on the day of inspection. Policies and procedures were in place for control of infection; this was covered in the induction-training programme for new staff. Staff confirmed that they had adequate supplies of protective clothing. There was evidence in staff files that staff had completed training in infection control. The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels were adequate to meet the needs of the service users and staff were trained to do their jobs. The recruitment procedures had improved and were adequate for the protection of the service users. EVIDENCE: The home is registered for 30 service users and at the time of the inspection there were 23 service users accommodated. Whilst the manager provided evidence that staffing levels in the home met the minimum guidelines set out by the Residential Forum, the rotas did not show when the deputy managers were on duty in the home or the full names of the staff. Staffing was arranged so there were 3 carers on duty between 7am and 10.00pm together with the two deputy managers working 37 hours each during the week. At night there were 2 carers on duty. The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 21 There was evidence from staff training records and staff surveys that the home had an active training programme, which included mandatory and service specific training such as moving and handling, fire safety, dementia awareness and arthritis awareness. It was identified from the records available that not all the staff had completed training in protection of vulnerable adults. The manager did not have an overview of the staff training at the time of the inspection which would make it difficult to identify individuals training needs and target training efficiently. The manager provided a copy of the overview of training prior to writing this report. The home was committed to staff receiving NVQ training and of 21 care staff employed 8 had achieved at least NVQ 2. The staff had some induction into the home but the records to evidence this were not always fully completed. There was evidence that new staff had completed most mandatory training. There was improvement in the recruitment procedures and adequate checks were completed prior to employment. POVA (Protection of Vulnerable Adults) 1st checks had been completed in all cases prior to employment but it is recommended that, other than in extreme circumstances, staff are not employed prior to the receipt of a full CRB (Criminal Records Bureau) check. The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 22 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An experienced but unregistered manager managed the home. The home was run in the best interests of the service users. The service users financial interests were safeguarded and their health and safety generally promoted and protected. Wedging of a fire door may put service users health and safety at risk. EVIDENCE: The current manager Helen Line has been in post since July 2006. Helen had been the registered manager of the Old library and had continued to work in The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 23 the home as cook since stepping down in 2003. Helen had not made an application to the Commission to become the registered manager at the time of the inspection. A system of monitoring the quality of the car provided had been implemented since the last inspection. The manager had completed a detailed self-audit of the homes procedures against the National Minimum Standards and the service users had been involved in a recent survey regarding the quality of the meals provided in the home although results had not been published. The manager had developed an action plan to improve areas where deficiencies had been identified. There were policies and procedures in place for all areas of practise, which had been regularly reviewed. There were very clear records maintained where the home was assisting service users with their finances and receipts were held for transactions. Detailed fire and environmental risk assessments were in place and individual risk assessments were held in care plans. The records held to show that fire alarms and emergency lights were tested but there was some duplication of these and one record showed that although tested regularly the fire alarm had not been tested weekly however another record showed that this had been completed weekly. Fire training had been provided via external courses and fire drills, although night staff had not been involved in fire drills. The night staff completed daily fire safety checks. Staff had received training in moving and handling and health and safety. During the tour of the building it was noted that one fire door to a service users bedroom had been wedged open the service user stated that this was for ease of access. There was evidence that equipment used in the home had been regularly safety checked or serviced. There was no evidence at the time of the inspection that the portable electrical equipment had been safety checked but this was provided prior to writing the report. Accident records were maintained and monthly log was completed to enable the manager to study the prevalence of accidents in the home. Staff had received training in first aid. The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 24 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 6 Requirement The registered person must update the service users guide and statement of purpose in relation to management changes. The registered person must ensure that the care plans reflect all the service users care needs and give specific directions for the meeting needs. The registered person must ensure that the care plans are reviewed monthly. (Previous timescale of 01/02/06 was not met) The registered person must make arrangements for the service users weight to be monitored regularly and records of loss/gain and actions taken maintained. (Previous timescale of 01/02/06 was not met) The registered person must ensure that refrigerated medication is securely stored. The registered person must ensure that all complaints are fully investigated. DS0000002908.V329560.R01.S.doc Timescale for action 01/05/07 2 OP7 15 01/05/07 4 OP7 15 01/05/07 5 OP8 12(1) 01/05/07 6 7 OP9 OP16 13(2) 22(3) 31/01/07 31/01/07 The Old Library Version 5.2 Page 26 8 OP18 13(6) 9 10 11 OP19 OP26 OP30 23(2) 16(2)(k) 18(1)(c) 12 OP33 24(2) 13 OP38 23(4) The registered person must ensure that all staff receive training in the protection of vulnerable adults and associated policies and procedures. The registered person must ensure that repairs to the blind in bedroom 20 are completed. The registered person must ensure that the home is kept free from offensive odours. The registered person must ensure that staff receive induction into the home to the Common induction standards and that records to evidence this are maintained. The registered person must ensure that the report in respect of the quality review is made available to service users. The registered person must ensure that fire doors are not wedged open. 01/06/07 01/05/07 01/04/07 01/05/07 01/06/07 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP15 Good Practice Recommendations The registered person should ensure that soft diets are served in a way that service users can be offered the individual foods separately, i.e. meat vegetables should be individually served and not mixed together. The registered person should ensure that the manager completes the process with the Commission to become the registered manager. 2 OP31 The Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Old Library DS0000002908.V329560.R01.S.doc Version 5.2 Page 28 - 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!