CARE HOMES FOR OLDER PEOPLE
The Shaw 169 Tollers Lane Old Coulsdon Surrey CR5 1BJ Lead Inspector
Claire Taylor Unannounced Inspection 12th September 2005 11:30 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 Shaw DS0000025855.V249154.R01.S.doc Version 5.0 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 Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Shaw Address 169 Tollers Lane Old Coulsdon Surrey CR5 1BJ 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) 01737 556 577 01737 556 386 Central & Cecil Housing Trust Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21 March 2005 Brief Description of the Service: The Shaw, located in a semi rural residential area of Old Coulsdon, is a detached property situated in its own grounds and within easy reach of the local village. It is registered as a care home for older people with the Commission for Social Care Inspection to provide care and accommodation for up to 25 service users. Central and Cecil Housing Trust own the home and is a registered charitable organisation. There are 25 single rooms, some of which have en suite facilities. Accommodation is set out over three floors with a lift to service each. Communal areas consist of three dining rooms and two lounges. There is a large well-maintained garden planted with mature shrubs and trees, flowerbeds and hanging baskets / window boxes and a water feature. There is a large wellequipped kitchen and adequate laundry area. Ample space for parking vehicles is available at the front of the property and the home is situated within easy reach of nearby transport links such as buses. The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced, took place over lunchtime and early afternoon and lasted three and a half hours. Time was spent talking with the residents and the home manager, Rona Bourke who assisted with the majority of the inspection. Several members of staff were also spoken to including the cook. All those who contributed to this inspection are thanked for their time. Prior to this particular inspection, the Commission did not receive a preinspection questionnaire for this service or any comment cards from either residents or their relatives. A brief walk round the premises took place and several bedrooms were viewed with the permission of the residents. Various records were checked concerning residents’ plans of care, staff files and the home’s general administration systems. What the service does well: What has improved since the last inspection?
The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 6 The manager has now been officially appointed as home manager and is awaiting an interview with the Commission to become registered. The Shaw continues to be an efficiently run home, where the health, personal, social and emotional needs of service users are well met. The staff team has remained largely unchanged resulting in stability and valuable familiarity for the residents. Staff have undergone further training in key areas including those specific to meeting the residents’ needs. One example included a training course on caring for people with hearing impairments. As required previously, risk assessments for the premises have been completed. These serve as means of further safeguarding the health and welfare of residents, staff who work there and any visitors that call to the home. What they could do better:
Six requirements were set that largely relate to record keeping. Given the home’s previous consistency in complying with requirements, the manager should have little difficulty in meeting them within the allocated timescales. Some minor improvements are needed with care planning records. Following the admission of new residents, the home must ensure that a care plan is developed for an individual and an appropriate review meeting is held following the person’s trial stay period. This is important, as it provides the resident and relative if appropriate, with assurance that the home is able to meet their needs. In addition, residents’ care plans must be reviewed on a monthly basis to evaluate whether individual needs continue to be met. While safety practices within the home are generally of a high standard, the premsies is still due a fire safety inspection. The manager has made efforts to address this and written to the fire authority. Evidence that the home complies with the Environmental Health Department was not available and this too needs addressing. Staff record keeping could be improved upon. All necessary documentation pertaining to staff must be kept in the home as required by regulations. I.e. up to date photograph of all staff. A copy of CRB/POVA check for one new staff was not available. At present, copies of police checks are held centrally by the owning organisation but need to be kept on staff files in the home. The Commission had received one formal complaint since the last inspection that was investigated by the owning Trust. Sufficient evidence was sent to the local office that the complaint was dealt with appropriately but records about the complaint and its outcome were not available in the home. Details of all complaints made must be kept in the home to fully comply with regulations. The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 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 Shaw DS0000025855.V249154.R01.S.doc Version 5.0 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 Shaw DS0000025855.V249154.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 and 5. Standard 6 is not applicable to this home as it does not provide intermediate care. Residents and their representatives are given information in advance of admission to ensure they are able to make an informed choice. Assessments are undertaken to evaluate needs prior to admission although the home must ensure that an appropriate review meeting is held and care plan is developed for a resident. Such lack of information means that the home cannot be certain that individual needs are being or will continue to be met. EVIDENCE: Three new service users had been admitted to the home since the last inspection. Their case files were examined in some depth. The Shaw uses its own pre-admission assessment tool and assessments had been completed appropriately for each resident at the point of their admission. Areas covered include hobbies, social/ cultural needs, dietary preferences, medical history and personal care. Mobility needs are assessed with risk plans completed for the prevention of falls. One resident, admitted in April of this year, did not have a care plan based on their needs assessment. Lack of full information concerning the provision of care could result in both residents and staff not being aware whether the home has the capacity and resources to meet
The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 10 individual needs. In addition, there were no records to demonstrate that the home had undertaken a review with the resident following the trial stay period. This is important as it provides the resident and relative if appropriate, with assurance that the home is able to meet their needs. The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 Care plans are generally well maintained although reviews need to be carried out more frequently to evaluate whether the home is meeting a person’s assessed needs. Healthcare needs are being well met by this home. Residents spoken with were happy that they were treated with respect and that their privacy was respected as much as was possible. EVIDENCE: Aside from the lack of a care plan for one new resident, individual plans of care are in place that detail all aspects of health, personal and social care needs. . Staff write daily notes about the residents’ well being with clear indication of the actual care given. On some files however, records showed that care plans were not being reviewed monthly. Even if the needs of an individual have not changed significantly, the staff must review the care plan on a regular basis to show that assessed needs continue to be met. Both the resident and relatives are involved in the care planning process although the manager should ensure that residents or their representatives sign in agreement with the plan wherever possible as some had not been completed. Records confirmed that the staff team monitor health needs to a very good standard and ensure that residents’ psychological needs are reviewed regularly. Residents are weighed on a monthly basis and appropriate records
The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 12 maintained. Service users are encouraged to maximise their mobility through walking and other gentle exercises. Falls are minimised through the use of risk assessments and individual guidelines. A monthly analysis on records of falls is carried out to ensure that no trends are forming and minimise incidents. Records indicate that the home maintains good working links with the local G.P. practice and residents benefit from an efficient, responsive service should a health concern arise. Doctors visit residents at the home regularly to review health needs as necessary. Likewise, district nurses call in to give treatment where identified. Residents are supported to access other community based health services including hospital clinics, chiropody, opticians and dentist. A number of residents kindly gave their views regarding the way staff treated them. All felt that their privacy was being maintained as much as possible and that they were treated with respect. Observation of the staff team interacting with the residents also showed that the carers were mindful of how they addressed individuals, and they were seen to be polite and friendly. The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 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 the following standard(s): 12,13 and 15 Social activities are well organised, creative and provide stimulation and interest for people living in the home. Residents are assisted to maintain contact with family and friends and links between residents and the local community are supported. Meals are nutritious, balanced and offer a healthy and varied diet for residents. EVIDENCE: Residents’ preferred social and leisure interests are recorded in their care plans and activity timetables are kept. A notice board is available which displays up to date information about activities and social events/ functions. The home also provides a newsletter for any interested parties. A senior staff member takes responsibility for arranging activities and a weekly programme of activities is displayed on the board. Those offered at the home include quizzes, discussion groups, reminiscence, bingo, singing and art and craft activities. Visitors from a local church group visit monthly to socialise with residents. Individuals have the opportunity to participate in Holy Communion as their faith so determines. Recent outings have included trips to a local garden centre and farm which residents said they enjoyed very much. Links between residents and their respective families are well supported by the home. Family and friends are invited to any social events held at the home as well as reviews. Relatives are encouraged to contribute their views and are kept well informed about the home through monthly meetings. Minutes of monthly
The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 14 service users meetings were available and detailed that staff consult with the residents regarding issues in the home including activities and menus. The home uses a contracted catering firm and two cooks are employed. Both these staff have worked in the home for some time and are familiar with the likes and dislikes of individual service users. The cook was interviewed during this inspection and is thanked for her time. She was able to clearly define her role in the home and efficiently described how the home’s catering practices are managed. Menus are planned in consultation with the residents. The menu is displayed on the notice board and records showed that residents’ choices are sought and recorded daily. An alternative menu is available and two residents had selected preferred dishes during this visit. The home caters for religious or cultural dietary needs as required. Meals are served in a choice of two dining rooms or individual bedroom, depending on the wishes of the individual. Residents were observed receiving appropriate support during lunchtime as well as being offered choices. The lunch provided was braised liver and bacon or cheese and potato bake with potatoes and a selection of vegetables. Meals appeared well presented and appetising. Residents spoken to were complimentary about the food quality. The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 Arrangements for complaints and protection from abuse are generally well managed and ensure that residents feel listened to and safe. Records of all complaints made should be available in the home however so that residents, relatives and staff are made aware of issues and any actions taken. EVIDENCE: Information about how to make a complaint is clearly provided in the Service User Guide with a separate summary leaflet of the complaints process accessible throughout the home i.e. posted on various notice boards for service users and their relatives / friends to read. A book is kept in the home to log both formal and informal complaints and concerns. Records showed that a resident had made one informal complaint and that the manager had dealt with the matter satisfactorily. Residents also have good opportunities to raise concerns through their monthly meetings. The Commission had received one formal complaint since the last inspection that was investigated by the registered provider, Central & Cecil Trust. Sufficient evidence was sent to the Commission local office that the complaint was dealt with appropriately and in accordance with the home’s policy and procedures. There was no record of the complaint or its outcome kept in the home however. The manager is reminded that records and outcomes of all complaints must be available in the home to ensure that residents, their relatives and staff are made aware of any findings and actions taken. The home operates systems to safeguard residents from abuse including vetting staff correctly and providing training on the prevention of abuse. There are numerous organisational policies to safeguard the residents welfare e.g. management of their finances, dealing with abuse and a whistle blowing policy to state what action to take should staff suspect anything untoward. The majority of staff have attended an adult protection training course with plans for others to go during the forthcoming year.
The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 The home is maintained, decorated and furnished to a good standard enabling residents to live in comfortable surroundings. Overall facilities are clean and safe although the home is due a fire safety inspection to demonstrate that the premises comply with legislation. EVIDENCE: The home is pleasantly decorated, furnished to a good standard and is fully accessible to all its residents via a passenger lift. There are many “homely” touches such as plants, photographs and flower arrangements. Adaptations have been provided throughout to aid those with reduced mobility. Radiators have been guarded. A loop system has been installed for the benefit of those residents who have hearing impairments. There is rear garden, which is accessible to all the residents and is much enjoyed in the summer months. All the communal areas are appropriately furnished and well lit Residents are thanked for their time to allow the inspector to see their rooms which appeared very personalised and furnished according to identified needs. Residents can lock their doors for privacy and lockable facilities are provided for valuables. A
The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 17 documented record of maintenance is kept and there is a “handyman” employed for the home to carry out essential repairs. Two requirements remain outstanding from the last inspection although it is acknowledged that the manager has made efforts to address them. To ensure that the home complies with the requirements of the LFEPA (London fire and emergency planning authority) the home needs a fire safety inspection. The manager has written to the fire authority however. Also outstanding is that no report was available from the Environmental Health Department and this must be obtained. A walk around the home showed it to be clean, pleasant and hygienic. Effective systems are in place to ensure good hygiene practices are observed and that the home is kept free from offensive odours. Policies and procedures to manage infection control are in place and cleaning rotas were signed and up to date. The laundry facilities were not inspected on this occasion although no concerns were identified at the last visit. (March 05) The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 and 30 There is a competent and stable staff team who clearly understand the needs of the elderly people living there and are provided with good training opportunities to do their jobs effectively. Recruitment practices are securely managed to maximise protection for the residents. EVIDENCE: Rona Bourke joined as acting manager in March of this year and was later officially appointed as home manager for the Shaw in June. The manager works full time and is generally supernumerary to staffing levels. She has an NVQ level 4 management qualification and is awaiting an interview with the Commission to become the registered manger for this service. Duty rotas seen indicated that sufficient staffing levels are maintained for the current resident group with three staff on each shift and two on waking nights. Ancillary staff include a contracted cook and domestic assistants. Positively, the staff remain unchanged with only one new staff being appointed since the last inspection. Residents commented positively about several long standing care staff who were described as “very helpful” and “ they take time to talk to me”. The organisation that own the home operates comprehensive recruitment policies and procedures that are specific to regulatory checks and probationary terms for staff. Various staff files were sampled including one for the newest employee. With the exception of the newest staff, files included evidence of a CRB check, references, training records, proof of identity and a job contract. The manager explained that the CRB and POVA check for the new staff was held centrally at the head office. The providers are reminded that all the
The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 19 necessary documents pertaining to staff must be held in the home and available to inspection. Additionally, three staff files did not contain a photograph and the former requirement therefore still stands. Training for staff is well managed. Personal development plans are used to identify training needs and the home continues to demonstrate efficiency in the area of staff training and development. The induction process for new staff includes both organisational learning outcomes and in house training relevant to the needs of service users. Sampled files contained good evidence that staff have undergone relevant training. E.g. areas such as moving and handling; food hygiene; first aid; fire; NVQ Level 2 and 3 for some staff; elder care and dementia training. A comprehensive training programme is available that provides a variety of courses for staff to update their skills and knowledge along with recognition of mandatory training that they must attend. The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 36 and 38 The home uses systems to ensure that quality of care is regularly appraised so that it can recognise where standards may have fallen and take action to resolve any issues. Residents are benefiting from a well-supported staff team who receive regular training, supervision and guidance from their manager. Good health and safety practices ensure that residents live in a safe environment and the welfare of residents and staff is protected. EVIDENCE: Effective systems are in place for quality monitoring which included general daily checks; regular audits of residents’ care plans, the environment and monthly visits by the registered providers in accordance with regulation 26 of the Care Standards Act. A ‘satisfaction survey’ is offered to service users on an annual basis; last completed in January 2005. A selection of questionnaires indicated positive views about the home and the care provided. From the findings, the home had produced an action plan and the previous manager had
The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 21 written to individual relatives to outline how the home intended to address any issues raised. This serves as a valuable method for involving residents and their families in appraising the home’s standards of care and making positive changes. Resident and staff meetings are held and also serve as a means of receiving feedback about the home’s operation. The manager is responsible for providing formal supervision to all staff members. Records of regular supervision sessions and annual appraisals were up to date. Supervision identifies what the member of staff does well, what they need to improve upon and what training they may need. There are good arrangements for ensuring safe working practices in the home. Examples include a daily walk round of the home/ environment check with outcomes recorded in the communication book. All staff members undergo training in safe working practices and comprehensive health and safety procedures are in place. All services, equipment and facilities are regularly checked and maintained in a safe state to maximise protection for all those living and working in the home. As required previously, the manager has completed detailed risk assessments for the premises in July of this year. All accidents and incidents are recorded appropriately and safety notices are posted throughout the home. A regular audit of accident records is undertaken as a part of the organisation’s quarterly service review. Fire drills are organised at regular intervals and fire alarms and equipment had been checked in August 05. Other maintenance records were not examined on this occasion as they were checked at the last inspection and all up to date. The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 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 2 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 X 3 The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? YES- 3 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 3 Regulation 14(1)(d) (2)(a) Requirement Following the admission of a new resident, the home must ensure that a care plan is developed and an appropriate review meeting is held following the person’s trial stay period. All residents care plans must be reviewed on a monthly basis. Records and outcomes of all complaints need to be made available in the home to ensure that residents, their relatives and staff are made aware of any findings and actions taken. The home arranges for a visit from the local fire brigade (LFEPA) to ensure that the premises comply with current fire regulations. (Timescale of 30.6.05 not met although it is acknowledged that manager has made a written request to the fire authority) The home arranges for a visit from the Environmental Health Department to evidence that the premises comply with requirements. Timescale for action 31/10/05 2. 3. 7 16 15(2)(b) 17(2) Sch.4 (11) 30/09/05 31/10/05 4. 19 23(4) 30/11/05 5. 19 16(2)(j) 23(5) 30/11/05 The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 24 6. 29 19(1)(b) The registered provider is also required to submit a copy of the report and any findings to the Commission. (Timescale of 30.6.05 not met) The registered manager must ensure that a recent photograph of every staff is kept on their personal files. (Requirement now outstanding from 30.9.04) 31/10/05 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 30 Good Practice Recommendations The carpet on the middle staircase is replaced due to an unpleasant odour. (Repeated from previous inspection. It is acknowledged that the home’s redecoration programme includes a plan to replace the carpet) The manager should ensure that the resident, wherever capable, and/or relative/ representative signs their care plan. 2. 7 The Shaw DS0000025855.V249154.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Shaw DS0000025855.V249154.R01.S.doc Version 5.0 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!
