Inspection on 10/11/05 for Thurlston House

This inspection was carried out on 10th November 2005.

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

Thurlston House 07/11/06

Thurlston House 25/05/05

Thurlston House 16/11/04

Thurlston House 02/06/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Thurlston House Victoria Hill Road Fleet Hants GU51 4LD Lead Inspector Mr Rodney Martin Unannounced Inspection 10th November 2005 09:00a 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 Thurlston House DS0000034233.V260839.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. Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thurlston House Address Victoria Hill Road Fleet Hants GU51 4LD 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) 01252 628520 Hampshire County Council Alice Lai-Kuen Cheang Care Home 49 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (49) of places Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 49 male and female service users in the OP category may be accommodated at the home. Up to 15 male and female service users in the DE (E) category may be accommodated at the home. Date of last inspection Brief Description of the Service: Thurlston House is a large residential care home, managed by Hampshire County Council, which was first officially opened on 26 March 1974. The home is over two floors with all the bedrooms on the ground and first floor. There is a large garden. Thurlston House is situated within a mile of Fleet town centre. Thurlston House is able to offer care for up to forty-nine older persons, in the category OP and up to fifteen service users in the category, DE[E], for those suffering from dementia. Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place between 9.50am and 5.0pm. The regulation manager, accompanied the inspector and was also involved the inspection process. The registered manager has been off work for some months and on the day of the inspection the inspectors met with the acting unit manager and three assistant unit managers. A tour the building was undertaken. A number of issues were identified and these are highlighted in the environment section under standards 19 to 26. Various staff members were spoken to as well as a number of residents. The four assistant unit managers have worked well as a team and covered the home in the absence of the registered manager. On the day of the visit the home was accommodating forty-three residents, which included a client on a short stay. Thurlston House has twelve males and thirty-one female residents. No complaints have been received since the last inspection and the contact with the home has only been through receiving notification of incidents within the home [Regulation 37 notification] and the monthly unannounced visit by the service manager [report under Regulation 26]. What the service does well: What has improved since the last inspection? Two new baths have fitted although they are not yet operational. Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 6 Since the last inspection the home has changed from a Nomad system to a Mandrax system [blister pack] for the administration of medication. 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. Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 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 Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 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 5 The home has a system in place to identify the physical and social needs of service users’, however, there is a lack of information about the mental health needs of residents. EVIDENCE: On the day of the visit Thurlston House was accommodating forty-three service users, which included one service user on a short stay. The home has six vacancies. All prospective service users are referred through a care manager from Adult Services [previously known as Social Services]. The assessment process is that once a referral has been made the home decides whether they can admit the prospective service user and that they meet the home’s registration criteria. All prospective service users are visited by a staff member and have the opportunity to spend some time in the home, prior to admission. Before a permanent placement is agreed, prospective service users are admitted on a trial basis to confirm that the initial assessments made are such that the home can meet their needs. A number of residents have had previous short respite stays in the home, prior to making a decision to want to Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 9 live permanently in Thurlston House. Unplanned admissions are avoided where possible. A lengthy discussion took place regarding the admission criteria of prospective service users coming to Thurlston House, especially for those who have an age related mental health problem. It was noted in the previous inspection report that the home needed to have completed some form of assessment of the current service users’ mental health needs to ensure that conditions of registration are met, with the home not accommodating more than fifteen clients in the dementia category. Following discussion with the acting unit manager the home has not carried out this exercise and so did not have a realistic number of those service users who fall within the dementia category [DE(E)]. The home needs to ensure that this matter is addressed. In discussion with several service users the opinion was expressed that it was “sad to see those people with dementia” in the home and they did not like to mix with them. Although care plans are discussed in the next set of standards, there was evidence that the recording of the mental health needs of service users still require further development, which is clearly linked to the assessment process on each service user. Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 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 and 9 The social, personal and social care needs are detailed in the service user’s care plan, however, this requires further development for those residents with an age related mental health problem. The deficiencies in the number of functional bathrooms compromise the bathing needs of service users. There were adequate systems in place to meet the medication needs of residents, however, the medication policies and procedures would benefit from a review. EVIDENCE: All service users’ health, personal and social care needs are set out in an individual care plan. These have been reviewed and contained the various assessments of activities for daily living, an assessment matrix, manual handling assessment, various risk assessments and the care needs required during the morning, afternoon and night shifts. There was action required in the previous inspection report that the home needed to develop the care plan to include all aspects of the care needs of those residents who have dementia. This process had commenced but was superseded by the home receiving a new set of care plans from Hampshire County Council. It was reported that all care plans [seventeen pages] are now to be transferred to the new format and this process has begun by the four assistant unit managers. They have been given a mandate to complete the care plan transfer by the end of November 2005. Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 11 The care plan mainly refers to activities of daily living with only a section on ‘memory’ and ‘communication’. The home needs to ensure that the care needs, within the care plan, of those with dementia is fully developed to enable any staff member to understand and implement the aim and objectives for that service user. There has also been a lack of staff training in dementia and this needs to be addressed. This will be monitored on the next inspection. In discussion with staff it was identified that residents are more dependent now. The home has four wings, two upstairs and two downstairs. There are two bathrooms upstairs and three downstairs. Two bathrooms are out of commission as new baths have been fitted but are not functional yet. Two of the working baths are very low and have cumbersome hoists [this is fully developed in the environment standards 19 to 26]. However, this has resulted in there not being enough baths for the number of residents accommodated and has caused a backlog for bathing. One staff member said that “we don’t have as much time to spend with residents” because of the shortage of baths. It was reported that all residents get a bath a week but not necessarily when they would ideally want it. However, there was evidence from talking with service users and staff members that the overall impression was that service users received adequate care. Since the last inspection the home has changed from a Nomad system to a Mandrax system [blister pack] for the administration of medication. The pharmacist puts up the medication into the blister packs, on a monthly basis. Medication not suitable for the blister pack or medication prescribed on a p.r.n basis [as and when required] is available in stock bottles and these are stored in the medication stock room. Thurlston House has two trolleys in use to accommodate the new medication system. There are currently no controlled drugs prescribed, apart from Temazepam. The acting unit manager and the four assistant unit managers are the only ones responsible for drug administration. The assistant unit managers have all had training in drug administration. Several issues were identified regarding the storage and disposal of medication. These were discussed with the management team and steps taken to rectify the issues. A jar of emulsifying ointment, dated 1/2001 was found in a cupboard in the bathroom on green wing. It was agreed that this would be removed and thrown away. One service user had been prescribed Omeprazol but this had been discontinued. There were still six tablets left in the pharmacist bottle. It was agreed that these would be returned to the pharmacist. Two boxes of Fybogel were not labelled. One box had the label torn and staff had no idea which service user this medication had been prescribed for. It was agreed that these would be disposed of. An unused tube of Daktacort was found in the medication refrigerator, prescribed in 2003. It was reported that this was no longer prescribed. Again it was agreed that this would be disposed of. Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 12 The home’s corporate drugs policy and procedure was available in the office. It was discussed updating the document to include relevant procedures pertinent to Thurlston House. The manager needs to ensure that all assistant unit managers are aware of the procedure location. Thurlston House DS0000034233.V260839.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): These standards were not inspected on this occasion. EVIDENCE: Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 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 The home has a satisfactory complaints procedure, which residents feel able to use and an adult protection procedure to safeguard residents from abuse. EVIDENCE: The home has a detailed and relevant complaints procedure. Residents, spoken to, were aware of whom to complain to, should they have a need to. One resident said that they welcomed CSCI inspections as well as the monthlyunannounced visit by the service manager [Regulation 26 visits] as they were there to monitor and ensure the well being of the residents. Thurlston House has a complaints’ book. The complaints were all in-house issues, relating to food and domestic matters. They had been resolved. Thurlston House has the corporate Hampshire County Council and adult protection procedure, which includes a whistle blowing policy. Staff receive training in preventing and dealing with suspected abuse. One staff member, spoken to, was aware of what to do in respect of possible abuse occurring in the home. There have been no incidents of abuse recorded in the home. Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 15 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, 20, 21, 22, 23, 24, 25 and 26 Although residents live in a clean and pleasant environment this would be further enhanced following improvement to the lighting on yellow wing and the pruning of the trees. There is a lack of suitable baths and bathrooms in Thurlston House, which needs urgent attention. EVIDENCE: Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 16 A tour of building took place. Parts of the home still require attention and issues from previous inspection reports were still outstanding. The home had notified the department of Hampshire County Council responsible for the building [PBRS - Property, Business and Regulatory Services] of the outstanding issues and the requirements made in inspection reports. However, despite chasing up when the work is to commence the management team had not had satisfactory replies. It was reported, from one assistant unit manager, that PBRS took four months to respond to emails requesting information on one issue. It was reported that a new fire system is to be installed and the lighting changed on yellow wing. The work was due to commence in November but a letter from PBRS, dated 8 November 2005, indicated that the work would now commence in early January 2006. It was reported that PBRS had contacted the home to inform them that a fly screen had been ordered for the kitchen rear door. The other issue requiring action was a pruning of the trees to give more light to that side of the building. It was reported that a date has been arranged for the work to commence. It is hoped that in the next few months there will be vast improvement in the lighting within Thurlston House. There are sufficient toilets and sluice rooms to meet the needs of the residents. Residents have personalised their bedrooms and each one is provided with sufficient furniture. Only single bedrooms are provided. Suitable locks are provided on bedroom, bathroom and toilet doors. The inspector observed several residents had their bedroom door key with them. The home was clean and free from adverse smells, on the day of the inspection. The inspector expressed concern at the current lack of bathrooms available for service users to use. Thurlston House has three bathrooms on the ground floor and two on the first floor. However, it was noted that two were out of action because although they have been fitted with a new bath they have not been connected yet, reducing the number of baths for forty-three service users to just three. [Although the Commission has agreed that facilities existing before 16 August 2002 would meet the Standards; the current standards expect there to be one bath for every eight service users.] The home is proposing to use the bathroom previously used by the sleep-in staff for residents’ use. However, this is a domestic bath and is against a wall, which is sufficient for only one carer to assist in bathing a service user. The bathroom was locked on the day of the visit. Two of the baths [blue wing and yellow wing] are too low. Staff need to go on their knees when assisting a service user to wash, which staff confirmed is not ideal. The hoists on blue wing and yellow wing are also cumbersome, given the size of the bathroom, and cause difficulties for staff manoeuvring residents into the bath. The baths have been assessed by a manual handling specialist occupational therapist. She sent an email to the home stating, “ the bath is very low also limited space for the staff to use the bath hoist due to the small load bearing wall. There are two options: one to replace the existing bath or Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 17 change this into a wet room…level access shower”. It was reported that the occupational therapist is going to liaise with PBRS. Although risk assessments have been completed this is an unsatisfactory arrangement and steps need to be taken to ameliorate the situation. There is still an outstanding issue regarding the upstairs bathrooms on green and blue wing. They have a glass skylight, which cannot be opened. On a sunny day the bathrooms become very warm, even before there is additional heat from running hot water in the bath. Although the bathrooms have an extractor fan, they are not efficient for the room. Staff confirmed that this is still could be a problem, even before helping the resident to have a bath. The conservatory has been condemned by the County Council but has still not been dismantled and the proposal to provide a new conservatory erected in another part of home. The conservatory is not used and is lying empty. The home was clean and free from adverse smells, on the day of the inspection. Thurlston House DS0000034233.V260839.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, 28, 29 and 30 The home has benefited from having a full compliment of assistant unit managers. There is a stable staff team ensuring that residents are supported, however the provision of dementia training for staff would ensure that the mental health needs of residents is fully met. EVIDENCE: The home aims to operate with five care assistants, working from 8am to 10pm, with three awake night carers. The duty rota for the week of the inspection indicated that the numbers on any one shift could fluctuate from day to day, with occasionally only four on a shift, for example, on the day of the inspection between 5pm and 6pm. The home is working to an agreed formula for calculating the number of staff hours required according to whether residents have high, medium or low needs. Built into the assistant unit manager’s hours is 50 of the time spent on ’the floor’. For the week of the inspection the home needed to provide 793 care hours and according to the duty rota was providing a total of 769 hours [this assumed that half the assistant unit manager’s hours were spent with residents, although often in reality it can be far less]. Three night staff members are currently on an NVQ level 2 course [National Vocational Qualification]. Since the last inspection the home has recruited four new carers. The file of new carer was seen. This included a copy of the application form, written references, proof of identity, a relevant work permit and a copy of their CRB [Criminal Records Bureau check]. All new staff Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 19 employed by Hampshire County Council Adult Services Department have a nine session induction programme, for two days a week over a month; which includes communication skills, first aid and manual handling. Thurlston House is currently thirty-one hours down on day care hours, twenty night care hours, sixteen domestic hours, seven kitchen assistant hours and seventeen admin: hours. There are no laundry hour vacancies. One assistant unit manager is responsible for training and has been updating the folder of each staff member’s training log. Although the home has a training calendar from Hampshire County Council, with the various courses available through the year, it was reported that, staff are reluctant to travel any distance to attend day-courses. All staff have obtained a basic food and hygiene certificate. A course on infection control has been booked for 25 November and in January 2006 staff will have a care governance training session. Staff have a half-day refresher course on manual handling and emergency first aid, once a year. However, it was acknowledged that staff need to receive dementia training. A few staff members attended a four-day specialist dementia development programme course between October and December 2004 but none since. This needs to be rectified as a matter of priority within the home. Alternative suggestions were discussed to speed up this training and ways to cascade the various aspects of caring for older people with a diagnosis of dementia. The assistant unit manager wants to introduce ‘challenging behaviour’ training, as part of any dementia-training programme. One of the assistant unit managers was on a four-day first aid course, on the day of the inspection. All assistant unit managers will then have completed the first aid at work course as well as risk assessment course. Thurlston House DS0000034233.V260839.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): 31, 32, 36, 37 and 38 The acting manager has a good understanding of the areas in which the service needs to improve and has taken the necessary steps to develop these areas. She ensures staff are supported and that the residents’ health, safety and welfare are promoted through the home’s practices. EVIDENCE: The current registered manager is off work and the home is being managed by a locum unit manager. The last report the Commission received regarding the monthly unannounced visit by the service manager on 18 October 2005 [report under Regulation 26] stated, “whole of the management team given supportive comments from staff. The acting unit manager continues to have positive impact”. This was observed during the inspection. Thurlston House has a full compliment of four assistant unit managers. Each assistant unit manager is responsible for a wing each in the home, the carers Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 21 working on that wing and the service users. They also have designated tasks within the home, training, fire responsibility et cetera. The manager supervises the management team, who in turn supervise the rest of care and domestic staff. One staff member confirmed that she receives monthly supervision. The manager communicates a clear sense of direction and leadership which staff and service users understand. There are regular staff and separate management team meetings. Samples of records the home is required to keep were inspected. These were found to be satisfactorily maintained. The fire log was inspected and the records indicated that the fire safety equipment had been tested and serviced within the guidelines. A fire risk assessment was completed on 23 July 2004. The home has had six fire drills this year. There was evidence of regular staff fire training. As noted in the environment standards the fire alarm is to be upgraded with the work due to commence in early January 2006. Thurlston House DS0000034233.V260839.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 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 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 3 2 3 2 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 3 2 Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 23 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 2 Standard OP30 OP21 Regulation 18(1)(c)(i) 23(2)(j) Requirement The home must ensure that staff receive training in dementia. The home must ensure that the baths are fully functional and suitable for service users’ needs. The resident’s mental health needs must be clearly detailed in the care plan to inform staff of the care required. Outstanding since 31 July 2005 Timescale for action 31/03/06 31/12/05 3 OP7 15(1) 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Thurlston House DS0000034233.V260839.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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