Inspection on 26/07/07 for Tralee Rest Home

This inspection was carried out on 26th July 2007.

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

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

Other inspections for this house

Tralee Rest Home 26/06/08

Tralee Rest Home 29/01/07

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

CARE HOMES FOR OLDER PEOPLE Tralee Rest Home 38-40 Tankerton Road Whitstable Kent CT5 2AB Lead Inspector Michele Etherton Key Unannounced Inspection 26th July 2007 09:40a 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 Tralee Rest Home DS0000067902.V345292.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. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tralee Rest Home Address 38-40 Tankerton Road Whitstable Kent CT5 2AB 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) 01227 276307 01227 264598 Baldev Krishan Sohal Mrs Alison Farmer Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 2007 Brief Description of the Service: Tralee (the Service) is registered to provide accommodation and personal care for 25 older people (service users) who have special mental health needs. This means that they experience a reduced ability to recall events and to organise their thoughts. The premises are two older two-storey properties, which have been joined together and extended. There are a total of 23 bedrooms, which means that if full, two of the bedrooms would have to be used for shared occupancy. In practice, all of the service users have their own bedroom. Each bedroom has a private wash hand basin and 11 of them also have a private toilet. There is a stair lift which runs up to the first floor and which means that service users have step free access to all parts of the internal accommodation. The premises are fitted with a call bell system which is designed to help service users call for assistance should it be needed. The Service is set back a little from one of the main roads into Whitstable. To the rear of the property, there is an enclosed garden. The nearest shops are about one half of one mile away. The Registered Provider is understood to supply information to prospective service users through a variety of routes. These include the provision of a Service Users’ Guide. This is a brochure that outlines the principal features of the facilities and services available in the Service. There is a document called a Statement of Purpose available for review in the Service. This gives a more detailed account than does the Guide. Also, the Registered Provider ensures that a copy of the most recent Inspection Report from the Commission is available for reference in the Service if requested. The range of fees charged currently for residence in Tralee, runs from £367.82 to £450.00 per week. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this service has taken account of information received by CSCI since the last inspection including pre-inspection information supplied by the home in the form of an annual quality assessment form and an agreed improvement plan. Survey responses from relatives and people using the service have not been received. All key standards have been inspected in addition to others where previous requirements are in place or outcomes were evident during the site visit. The focus of the inspection was to assess progress made by the service towards addressing many of the outstanding shortfalls identified at previous inspections, and that timescales for achieving them detailed within their improvement plan are being adhered to. During the site visit, three relatives and four staff members were spoken with in addition to the manager and the provider. People living in the home were observed and spoken with throughout the site visit, although their ability to engage fully in discussing their experience of living in the home was severely impacted upon by their dementia, and resulting communication problems. A partial tour of the premises and a review of some documentation was also undertaken during the site visit. The home has made significant progress in addressing the majority of outstanding requirements, and this is reflected in the quality ratings awarded for some of the outcome groups, however, those requirements remaining in addition to those issued at this inspection will impact on the overall rating awarded to the service on this occasion. What the service does well: People residing in the home experience a comfortable, bright, clean environment that has a relaxed, friendly and pleasant atmosphere. There is a culture of respect and understanding amongst current management and care workers for the people living in the home. Relatives commented favourably on the support and care offered by staff in maintaining the health and welfare of the person they visit in the home, and their general observations on the welcoming atmosphere of the home, and recent improvements. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 6 Care workers were observed to interact well with people living in the home, demonstrating kindness, patience, and good insight into their day to day needs and well being. What has improved since the last inspection? What they could do better: The home has partly addressed three outstanding requirements in respect of developing an activities programme for people in the home, improving the recruitment procedure and developing systems for quality assurance. An assessment of progress in these areas found that some shortfalls still exist or improved practice has not yet been implemented, therefore further work is needed. The home maintains equipment used to support people living in the home,, however, the condition and servicing of wheelchairs, and the suitability of a downstairs hoist were identified as areas that impact on the health and safety of people in the home and need to be addressed. There was a lack of information as to who is responsible for the individual finances of people living in the home, and access to personal allowance monies. The home is required to establish and record these arrangements. Four recommendations for improved practice have also been made with regard to updating the Statement of Purpose and user guide to reflect recent changes Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 7 in accommodation and clarity around types of care offered. Improved cleaning frequencies for the dining area carpet. Implementation of Nationally approved staff induction standards and assessment of competency. That staff participating in fire drills are clearly recorded as such. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3.6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the service and its terms and conditions needs further clarity. Improvements have been made to the process of assessment but until used its effectiveness cannot be judged. The home is not resourced to provide an intermediate care service. EVIDENCE: People coming to the home are provided with a range of information about the service offered. Following recent change in use of some previous communal facilities, this information will need to be updated to ensure these changes are made known. It was further suggested that greater clarity is provided within this documentation regarding the types of care offered by the home and how they differ from each other, these are recommendations for improvement. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 10 The provider has now reviewed the contract/terms of conditions document following some omissions highlighted at the last inspection; the relevant parts of this information should be routinely made available to all residents irrespective of their private or public funded status. The admission and assessment process have been reviewed by the new manager, and a more detailed and holistic assessment of need developed. An absence of admissions since the last inspection, however, has meant that the effectiveness of these changes could not be assessed on this occasion. The home is not resourced to provide an intermediate care service Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual health and personal care needs of people in the home are well supported in a manner that respects their dignity and right to privacy. People who live in the home are better protected by improved management of their medication. EVIDENCE: A sample of care plans viewed at the site visit indicated that the new manager has made good progress in introducing a more person centred approach. Care plans have been rewritten and there is evidence now of routine review; staff report they are more actively involved in writing care plans. Some minor improvements to detail were discussed at inspection. The manager demonstrated good awareness of the need to seek consents for some aspects of care that could be construed as restrictive, but was reminded of the need to ensure care plans record this information in addition to provision of consents. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 12 Care plans viewed indicated an awareness of risks, and where these are identified assessment of risk and interventions needed have been made. The manager has implemented a new record for ensuring that health contacts are recorded and monitored, relatives spoken with indicated that the health needs of their respective relatives were well supported and they are kept informed of any changes or concerns around their relatives well being. The home diary provided evidence of hospital and routine health appointments for people in the home. Observation of staff practice and a review of documentation indicated that arrangements for the administration and recording of medication are appropriate. Improvements in the storage of medication within the home have been implemented addressing an outstanding requirement; this is an area that would benefit from further improvement and consideration should be given as to how this could be achieved. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in the home would benefit from a more varied activities programme, they are supported to maintain a level of independence and exercise choice; they are enabled to stay in touch with friends and family and their visitors made welcome. People in the home enjoy a varied and wholesome diet. EVIDENCE: The home has reviewed its activities and both staff and relatives reported that people in the home respond positively to musical entertainment. Records of participation in activities and observation during the site visit indicates that the current range of structured single activities fail to stimulate residents. Staff were observed to interact well with residents, and were enabling of residents to make choices and decisions about what they wanted to do. Staff were observed sitting and chatting with residents, and in some instances trying to engage them in an activity. Clearly this is an area that would benefit from building on the skills and strengths of the staff team in engaging with residents and offering a more varied and stimulating range of activities each day rather than one activity. This requirement has not been fully met at this time. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 14 Relatives spoken with reported that they were always made to feel welcome at the home and found staff approachable and friendly, and the atmosphere was always good in the home. There is a lack of clarity around the financial affairs of people living in the home and this has been addressed in more detail within standard 35. People in the home where able to do expressed their opinions and views and were assertive in their interactions with staff. Staff were observed to demonstrate kindness and patience in supporting people around mealtimes, they were proactive in asking residents if they were in need of drinks, and these and small snacks were offered routinely outside of the usual teatimes. Arrangements around meals and snacks are flexible and one person was observed breakfasting late. Staff were observed offering discreet and practical support to those who needed help with their meals and this enabled individual residents to retain a degree of independence. Relatives expressed positive views on the quality and quantity of food provided. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home and their relatives feel listened to and that their views are acted upon. Staff awareness and practice safeguard people living in the home on a day-to-day basis EVIDENCE: Pre-inspection in formation supplied by the home indicates no complaint shave been received since the last inspection. There is a complaints procedure and whilst many were able to express their views they might not be able to make use of the complaints procedure over a protracted period of investigation. Staff were observed talking and listening to residents, and were responsive to requests made by them. Discussion with relatives indicated that they felt listened to by the provider and manager, who they felt acted upon any concerns they might have. This has been helped by the implementation of the relatives meetings An adult protection alert was raised previously regarding a former resident this has now been closed and the home has addressed shortfalls identified from this. Staff have now received training in adult protection and both the staff spoken with and the manager demonstrated a commitment to safeguarding the welfare of the people living in the home and ensuring their overall well being. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 16 The manager demonstrated an understanding of restraint issues and the need to ensure consents in respect for some restrictions are in place. Discussion with staff highlighted their awareness of some challenging behaviours and how these might be dealt with using diversion techniques and this is supported in relevant care plans. Clarity is required around the finances of individuals in the home but this has been addressed at standard 35. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a friendly and comfortable atmosphere. Improvements to the maintenance and general upgrading of the home has provided a more pleasant and safe environment for the people living there. EVIDENCE: The home provides a bright, comfortable and clean environment; the atmosphere is welcoming and friendly. The provider has made very good progress in addressing all of the outstanding environment requirements issued at the last and previous inspections. Where this has impacted on facilities offered within the home, e.g. change of use of conservatory, visitors shower and toilet area, this now needs to be reflected in the Statement of purpose. The fire service has confirmed their satisfaction with current fire arrangements and improvements to fire training and fire drills supports this. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 18 It was noted that wheelchairs owned by the home are not routinely serviced and footplates are missing, this could place a health and safety risk on frail and vulnerable clients and risk injury. In addition the site visit highlighted resident concerns and distress in respect of a downstairs hoist used for bathing, clearly equipment used to support people in the home must be suitable to their needs and used because it is appropriate and not because it is there the home is required to address these matters. The carpet in the dining area has been replaced but this is heavily stained, staff reported that they have a carpet cleaner and that the carpet is shampooed but the frequency of this needs review and this is a recommendation. A good standard of cleanliness is maintained in the home and staff were observed making use of protective clothing throughout the site visit. The provider and manager recognise that further upgrading works are needed and were advised to incorporate these into overall development plans for the home that should incorporate a more proactive programme of maintenance. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Members of staff are available in sufficient numbers. Ongoing improvements to the recruitment, training and development of staff will help safeguard People living in the home, and ensure staff fitness and competency to support them effectively. EVIDENCE: The manager is committed to ensuring a good level of staffing commensurate to the needs and dependency of the people in the home is maintained. Staffing levels were good during the visit, and discussion with staff and relatives highlighted no present concerns. There has been some staff movement following the sale of the home and the departure of the previous manager, this has now settled but has impacted on the numbers of staff qualified to NVQ2 level. Pre-inspection information supplied by the home indicates that whilst numbers of qualified staff are currently below 50 , a programme of qualification training is in place and, the numbers of trained staff will exceed 50 again in the year 2007/2008 with plans for more staff to train. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 20 An outstanding requirement to ensure that the recruitment of staff is more robustly undertaken, has only partly been addressed with appropriate security checks and vetting now in place, however, ongoing shortfalls in the pursuit of detailed applications forms, quality of references accepted, evidencing interview processes and offer letters etc remain and now need to be addressed. The provider has made a significant investment in the training of staff, whilst not all core training has been achieved the majority has been addressed or is booked to take place, some training is also being undertaken through distance learning courses. The new manager recognises the importance of keeping staff training updated and has implemented a training matrix and individual staff training profiles to support this. Whilst there is evidence of some induction training of new staff, supporting documentation viewed at inspection is not in keeping with nationally agreed Induction standards established by Skills for Care and competency assessment of staff cannot be evidenced, it is recommended that to ensure consistency of quality and content of induction, a programme that has a nationally approved content is implemented. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is being effectively managed and progress made to address shortfalls in standards to ensure the safety and well being of people living in the home. Quality assurance systems need further development, and clarity needed in respect of the finances of people living in the home. The health and safety of people living & working in the home is generally promoted and protected. EVIDENCE: The new manager has experience of working in the care sector and demonstrates a good understanding of what improvements she would like to see implemented. She expresses a commitment to providing a quality service, and has already made a significant impact on the documentation in the home Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 22 and on the staff residents and relatives, all of whom seem to like and respect her. Staff spoken with indicated that the change of ownership and the loss of the former manager had been an unsettling time for all of them but they spoke positively of the new manager who they found very approachable. Staff meetings are now being held and staff said they felt listened to, found the new manager supportive of them and expressed faith in her ability to manage the home effectively. This was confirmed by relatives who found the new manager very nice, felt they could raise issues with her and these would be acted upon, there was a view that improvements had been made since she started. Staff confirmed that the manager observes their practice and will discuss this with them if necessary, formal supervision sessions although timetabled for staff have not yet taken place until the manager and senior carers have been suitably trained to undertake this task. Some progress has been made by the new manager in respect of Quality Assurance, a range of audit tools for various aspects of the service have been developed and are still to be implemented, the manager has introduced relatives meetings and these have been well received. Consultation with a wider group of relatives, other stakeholders and seeking feedback from people living in the home are also areas for development. As is the analysis of such feedback and evidence of how this influences service development, this remains an outstanding requirement. At present only one person living in the home has access to any personal allowance money, there is a lack of clarity as to the financial arrangements for the rest of the people living there, and the home is required to establish the financial arrangements for individual clients and who is responsible for personal allowance monies, the home should also ensure that each resident has some small some of personal allowance for their use should they need it or request anything. Previous shortfalls in electrical wiring and gas installation servicing have now been addressed. Servicing of fire alarm and fighting equipment has also taken place. Fire drill records have been implemented but would benefit from the names of participants being recorded for each drill and this is a recommendation. Accidents records are appropriately completed and currently indicate a minimal number of accidents have been recorded since the last inspection. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 X 3 Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 12 Requirement The Registered Provider should ensure that a suitably detailed review is completed of the activities included within the social calendar. This should be based in part upon a consideration of which service users are electing to participate in which of the activities that are available currently. (Partly met within previous timescale of 1/5/07) Equipment used in the home for the care and support of residents must be in good order and s appropriate for the needs of the service users as determined by the manager or other care professional. The Registered Provider must ensure that suitably detailed employment histories are obtained for staff and suitable personal references are obtained. (Partly met within timescale of 1/3/07) DS0000067902.V345292.R01.S.doc Timescale for action 30/09/07 2 OP22 23(2)© 30/09/07 3. OP29 19 01/09/07 Tralee Rest Home Version 5.2 Page 25 4. OP33 24 The Registered Provider should 01/10/07 introduce a suitable internal quality assurance programme. This should include provision for all of the service users (and other necessary stakeholders) to be consulted about the operation of the Service. Also, there should be provision for service users (and other stakeholders) to be informed about the Registered Provider’s intentions to progress any suggested improvements.(partly met within timescale of 1/7/07) The home is required to establish 30/11/07 the financial arrangements for individual clients and who is responsible for personal allowance monies, the home should also ensure that each resident has some small some of personal allowance for their use should they need it or request 5 OP35 13(6) 16(2)(l) 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 OP1 Good Practice Recommendations Statement of purpose and user guide information to be updated to reflect change of use of some communal facilities used by people in the home or their relatives, and greater clarity to be provided around the types of care offered within the home. More frequent cleaning of dining room carpet needs implementing. To ensure consistency of quality and content of staff induction, the home should implement a programme that has a nationally approved content, and can demonstrate that staff competency is appropriately assessed. DS0000067902.V345292.R01.S.doc Version 5.2 Page 26 2 3 OP20 OP30 Tralee Rest Home 4 OP38 Fire drill records have been implemented but would benefit from the names of participants being recorded for each drill and this is a recommendation. Tralee Rest Home DS0000067902.V345292.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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