Inspection on 31/05/06 for The Sycamores

This inspection was carried out on 31st May 2006.

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

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

Other inspections for this house

The Sycamores 20/02/09

The Sycamores 23/01/08

The Sycamores 17/11/05

The Sycamores 24/05/05

The Sycamores 04/11/04

The Sycamores 04/06/04

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 Sycamores Norton Road Wakefield WF1 3PB Lead Inspector Elizabeth Hendry Key Unannounced Inspection 31st May 2006 08:25 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 Sycamores DS0000035670.V290460.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 Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Sycamores Address Norton Road Wakefield WF1 3PB 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) 01924 379994 sycamores@tri-care.co.uk Tri-Care Limited Mrs Elizabeth Parr Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 2005 Brief Description of the Service: The Sycamores is a purpose built care home which can accommodate up to 40 older people aged 65 years and over. It was registered in January 2003. The home is built on two levels with all single en-suite rooms. It is sited in an urban area close to the centre of Wakefield at a convenient site for all forms of transport. There is a large car park to the front of the building. The home is easily accessible to local shops, church and public houses. The grounds and gardens to the home are well presented and accessible to service users. As of the 31st May 2006 fees ranged from £350 to £500 per week dependent upon the assessed individual need. The home has a service user guide that provides information about their service for current and prospective residents. A copy of this guide is provided to all prospective service users by the management of the home along with a copy of the most recent inspection report. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s annual inspection, the visit took place on an unannounced basis between 08.25 am and 1.00 pm. As part of this key inspection, CSCI have had contact with the following people. Residents, their relatives, the service provider, staff members, social workers and GPs. During the site visit records, a tour of the home was undertaken, along with observations and discussions with both residents and staff. Ten resident questionnaires were sent out. At the time of writing this report 6 had been returned. In writing this report, information and evidence was not only obtained by way of visiting the home, but information and evidence was obtained from monthly provider visit reports and notifications sent to the CSCI since the last key inspection in November 2005, questionnaires, and the last inspection report. The inspection has concluded that residents’ needs, both personal and recreational, are generally met. Residents live in a relaxed and informal homely environment. The inspector would like to thank the residents, deputy manager and staff for their hospitality and patient co-operation throughout the inspection. What the service does well: Of those residents spoken with, all spoke highly of all members of staff commenting that nothing is ever too much trouble. Staff spoken with had a sound understanding of each resident’s personal needs and abilities, and were able to communicate effectively with those in their care. Individual care plans and resident records sampled are kept in good order with frequent reviews, thus ensuring that any changing needs are always met. Support systems in place within the home ensure that both residents and members of staff have access to either a member of the care team or management to discuss any concerns as they may arise. Residents live in a welcoming, relaxed and homely environment, which is well maintained and furnished to a high standard. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 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 Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Residents move into the home following an assessment of their health, personal and social care needs. EVIDENCE: The home’s terms and conditions of residence and resident contract identify what is and what is not included in the weekly bed fee. Information regarding the trial period, notice of termination of contract and services available within the home is also included within the contract and service user guide. Care plans viewed identified the personal care needs and abilities of each resident, and the methods in which care staff can meet these needs. The Deputy Manager and staff spoken to during the site visit confirmed that The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 9 residents’ care plans are developed based on the pre-admission assessment which is undertaken by a senior member of staff. The home’s pre-admission assessment for residents determine the level of need in the following areas: personal care, mobility, communication, family involvement, medication and medical treatment, social and recreational interests. Reference to care management assessments were present within some residents’ files. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement is based on evidence gathered both during and before the visit to this service. Detailed information of residents’ health, personal and social care needs are set out in an individual plan of care. Residents are not fully protected by the home’s medication policies and procedures, as some administration errors were identified. Records viewed identified that residents’ health care needs are met. Residents are always cared for in a manner that maintains their dignity and affords respect. EVIDENCE: Four individual care plans were inspected on a sample basis. The plans contained relevant information on the care required to meet the residents’ health and personal care needs. In addition to this, individual life histories, The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 11 family dates, hobbies and interests were also recorded to provide a holistic approach to each resident’s care. Of the four care plans examined, all showed signs of regular review with evidence of resident and, where appropriate, family involvement, risk assessments contained an adequate level of information for staff to follow to prevent residents being placed at unnecessary risk. Individual care plans held records of healthcare appointments with detailed information of their outcomes being documented. Staff spoken with during the visit confirmed that any health or welfare problems identified are quickly addressed. Residents spoken with spoke positively about their personal care needs being met. Resident questionnaires returned to CSCI following the visit indicated that residents either always or usually receive the care and support required. Of the five relative questionnaires returned and six general practitioner and health professional questionnaires returned, all were satisfied with the overall level of care provided. Daily records contain sufficient information and are consistently completed detailing the individual’s activities for the day and staff observations. The recording, administration and storage of medication was inspected on a sample basis. Records kept of the medication being received into and leaving the home have not always been accurately recorded, which may result in staff confusion when managing and administering residents’ medication. Appropriate arrangements are in place for the disposal of the medication. Medication administration records are completed at the time of administration. The Deputy Manager confirmed that only members of staff who have received training in the safe handling of medication are involved in the management of residents’ medication. The deputy manager spoke of residents receiving regular medication reviews with their chosen GP. All of the residents spoken to at the site visit complimented the dedication of the care staff, commenting that “nothing is ever too much trouble for them”, one resident added that “they always have time to listen and they take a genuine interest in how I am”. Resident questionnaires returned to CSCI following the visit indicated that residents either always or usually receive the care and support required. Throughout the site visit, staff were observed communicating and interacting well with residents and, at all times, maintaining the dignity and respect of each individual. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Discussions with residents and relatives described how, on the whole, the lifestyle they experienced within the home met their expectations and preferences and satisfied their social and religious interests and needs. Residents maintain contact with family and friends and members of the local community as they wish. Residents, on the whole, are encouraged and supported to exercise choice and control over their lives. Residents receive a varied and nutritious diet, within a pleasant dining environment. EVIDENCE: Activities available within the home offer variety and choice to the majority of residents, with adequate provisions being made for those residents who are The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 13 less able to participate. The Deputy Manager spoke of staff assisting residents to participate in a weekly programme of activities. Evidence of residents’ personal preferences being sought in relation to activities and interests were clearly documented within each individual care plan and, of those residents spoken with, all were very pleased with what was available. Within those care plans sampled, individual interests had been clearly recorded, within daily records reference had been made to what activities had been undertaken. On the day of the site visit, residents were enjoying reading, watching films and chatting to one another. An activity timetable was on display within the entrance hall detailing forthcoming events such as dominoes, music appreciation, bingo, and arts and crafts. Of the six resident questionnaires returned, one stated that there were always activities arranged in the home that they can participate in, two said there were usually activities, two sometimes and one never. Many residents were sitting within the communal lounges chatting to one another. One resident said “I enjoy doing the little jobs that I would have done had I been in my own home, like laying the table, watering plants and things”. Staff members were very busy on the day of the site visit, however they were observed being very responsive to residents when anything was asked of them. Throughout the visit, residents’ family and friends were visiting. Five relative surveys were returned to CSCI following the site visit, all indicated that they were made to feel very welcome at the home whenever they visited. Discussions with residents were very complimentary about the food, confirming a wide range of choice, with all meals being tasty and of a good quality. Staff confirmed that snacks and drinks are available throughout the day. Menus showed careful planning and indicated choices available for each meal. Of the six questionnaires returned, residents identified meals were always or usually to their taste. The presentation of the dining room was of a good standard with fixtures and fittings being domestic in nature. Dining tables had been arranged in a layout that encourages small groups of residents to converse during mealtimes. Staff spoken to said that, for those residents who do not wish to eat within the dining room, a tray is provided in their bedroom or lounge area. It was observed that those residents requiring a greater level of care or who had speech difficulties were offered the same choices as those more able, for example regarding what clothes to wear, where they would prefer to sit and what they would like to eat. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement is based on evidence gathered both during and before the visit to this service. Residents and relatives could be confident their complaints would be listened to and acted upon. Staff’s knowledge of adult protection varied, some were unclear as to the procedures to follow should they suspect any abuse at the home, therefore refresher training in this field would be of direct benefit to staff and residents. EVIDENCE: Of the six resident questionnaires and five relative questionnaires returned, all were aware of how to complain and who to speak to if they weren’t happy. There was a detailed record of complaints held within the home, with sufficient information regarding the nature of the complaint, timescale and the action taken. A copy of the Wakefield adult protection policies and procedures was available within the staff office. Of those staff spoken with, some were unclear as to the procedures to follow when reporting possible cases of abuse. All staff understood that the local authority had an adult protection team but were unaware of how to contact external bodies regarding adult protection The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 15 instances. Two members of staff were unaware of the Protection Of Vulnerable Adults (POVA). Although three out of five training records sampled indicated that abuse awareness training had been undertaken, a need for a refresher in this subject would ensure the safety and well being of residents. Enhanced Criminal Records Bureau checks and POVA First checks were absent for one of the five care staff files sampled. Records viewed did not indicate that these had been applied for, however confirmation received from the deputy manager confirmed that this had been applied for and that a POVA first check had been sought by the Commission. At the time of writing this report the home had yet to submit copies of these checks. No outstanding adult protection alerts were in place at the time of compiling this report. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 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 and 26 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. The standard of the environment within the home is good providing service users with an attractive and homely place to live. Infection control measures are in place which promotes the wellbeing and health of service users and staff. EVIDENCE: A tour of the home was undertaken, a good standard of decoration and furnishing was found throughout the home. The majority of fixtures and fittings were domestic in nature. To the rear and front of the property there are large garden areas, which are laid mainly to lawn, this provides additional seating and living space for residents during the summer months. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 17 The deputy manager spoke of redecorating bedrooms once they become vacant to ensure a welcoming and pleasing environment for all new residents. The home has an ongoing programme of maintenance and redecoration. All residents spoken to said that their bedrooms were comfortable and that they had everything they needed. One resident spoken to said that they find the home perfect for their needs. Feedback from six questionnaires identified the home as being “always” or “usually” fresh and clean, dependent upon staffing levels. On the day of the visit the home was found to be clean and no offensive odours were present. Staff training records sampled indicated that all staff receive infection control training on commencement of employment. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Residents’ needs are sufficiently met by the numbers and skill mix of staff. Some staff have achieved, and more are to begin, NVQ Qualifications thus ensuring that residents receive care from staff who have undertaken training relevant to their role. Residents are not fully protected by the home’s recruitment policy and practices. Staff are sufficiently trained and competent to do their jobs. EVIDENCE: Two of the resident surveys and two family and friend surveys returned to CSCI indicated that they felt that there were times when there was not enough staff on duty. However, on the day of the inspection despite staff sickness, residents’ care needs had been met and the home appeared to be running well. Residents spoken with were very complimentary about all members of staff. Staff were observed interacting well with all residents and, despite being very busy, were seen to take a proactive role with regards to meeting residents’ requests. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 19 Despite questionnaires indicating that there is not enough staff on duty, the staff rota confirmed that usually there are sufficient numbers of staff on duty to meet all of the needs of each resident. The Deputy Manager spoke of the home’s recruitment procedure and induction process. Records viewed confirmed that these policies are not always adhered to. Four staff files were inspected on a sample basis. Enhanced Criminal Records Bureau checks and POVA First checks were in place for three members of staff. One member of staff was found to be working within the home without a current enhanced Criminal Record Check or POVA first check. When questioned about this, the individual confirmed that both checks had been applied for and, as yet, had not been received. Information received prior to the site visit indicates that 44 of all care staff hold an NVQ level 2 in Care. At the time of the site visit, a number of staff were about to commence the award. During the site visit, the deputy manager provided the inspector with historical training records. These records indicate that the majority of staff have received mandatory induction training in key areas such as manual handling, infection control, fire safety, first aid and health and safety. There are a number of members of staff who lack training in some of these mandatory areas and therefore the registered person needs to address this as a matter of urgency. This will then ensure that residents receive care and support from appropriately trained staff at all times. Staff were observed approaching residents in a respectful manner and respecting individual preferences. Staff spoken to said that they receive informal supervision and support from their colleagues and formal supervision on a regular basis from the Registered Manager and deputy manager, and supervision records viewed during the site visit supported this. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 and 38 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Quality assurance procedures within the home ensure the home runs in the best interests of the service users. The management of the home is good and records are well managed. The manager is supported well by the deputy manager in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The health, safety and welfare of service users and staff are promoted and protected. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home places a high priority on ensuring quality care for all residents. In addition to the annual inspection from CSCI, the home undertakes monthly quality audits, frequent resident meetings and annual visitor questionnaires. The deputy manager said that the findings are then used to help improve the overall service residents receive. The deputy manager has a clear understanding as to the goings on within the home, residents spoke of the manager undertaking care and domestic duties when needed and providing an open door to discuss personal issues and worries. Staff confirmed that the manager and deputy managers are approachable and understanding and actively encourages their personal development. Records are generally well maintained, accurate and regularly reviewed. No financial records relating to both the home and the residents’ finances were inspected on this occasion, however no incidents surrounding the management of residents’ monies has been reported to CSCI. The Registered Manager provided details of the management of residents’ monies prior to the site visit. This confirmed that residents receive their full personal allowance to dispose of as they wish and that records are kept within the home of any transactions involving residents’ finances. Health and safety certificates viewed identified a consistent and responsible outlook being placed upon residents’ wellbeing within the home by the management team. Regular fire safety checks are undertaken and annual safety checks are undertaken for all appliances. Records viewed showed weekly fire alarm testing occurs. Training certificates viewed identified all staff undertake health and safety training as part of their induction process, with updates as required. Resident risk assessments are clear and concise giving staff clear instructions to ensure the safety of the resident. Of those sampled, all showed evidence of monthly review with any changes being recorded. Information received prior to the site visit indicated that regular fire safety checks are made, electrical and gas safety certificates are in date and that appliances are maintained in good working order. The home has made adequate provision for the removal of clinical waste from the home. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Ensure all medication received into the home is accurately checked and recorded on medication administration records. The home should obtain a pill counter to ensure accurate records. All eye drops are to be dated on the day of opening. Ensure all handwritten entries on medication administration records are countersigned. New employees must not start work in the home until full and satisfactory information relating to them has been obtained via a POVA/POCA check, and a CRB check in accordance with the department of health guidance. This was required at the 02.12.05 inspection. All staff files must contain the required information as detailed in schedule 4 of the Care Homes Regulations 2001. Timescale for action 01/09/06 2. OP29 19 01/09/06 The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP30 OP18 Good Practice Recommendations Minimum of 50 of staff achieve NVQ level 2, as on schedule to achieve. Provide all staff with refresher training in the homes adult protection policy and procedure to ensure the safety and well being of service users. The Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Sycamores DS0000035670.V290460.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!