Inspection on 16/05/06 for Truscott Manor

This inspection was carried out on 16th May 2006.

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

Truscott Manor 26/07/07

Truscott Manor 19/12/05

Truscott Manor 03/06/05

Truscott Manor 23/11/04

Truscott Manor 25/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Truscott Manor Lewes Road East Grinstead West Sussex RH19 3SU Lead Inspector Mrs A Peace Unannounced Inspection 16th May 2006 10:00 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 Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 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. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Truscott Manor Address Lewes Road East Grinstead West Sussex RH19 3SU 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) 01342 314458 01342 317240 info@truscott.wanadoo.co.uk Frannan International Limited Mrs Caroline Joan White Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May admit one service user between the age of 60 and 65. Date of last inspection 19th December 2005 Brief Description of the Service: Truscott Manor is a care home providing nursing care and accommodation for 41 people in the category of older people. Frannan International Ltd owns the service and the Responsible Individual on behalf of the company is Mrs N Kassam. The home is located in a rural setting in extensive grounds on the outskirts of East Grinstead, shops and other amenities are a short drive away. Resident’s accommodation is on two floors, a passenger lift is available but does not serve all rooms. Communal accommodation is available on the ground floor. The majority of the homes bedrooms are single and 19 have en-suite facilities although showers are not connected to the mains. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors between the hours of 10am and 3pm on 16th May 2006. This inspection is the first inspection for the year 2006-2007. It is called a key inspection and will determine the frequency of visits/inspections hereafter. Prior to the inspection, information was requested and received from the home in the form of a questionnaire. Three new policies and procedures for the home were also submitted. Records held on file and information received form the home since the last inspection was reviewed. A general tour of the home was undertaken and the majority of rooms visited, there was a nice atmosphere in the home and staff were cheerful going about their work. A case tracking exercise from records of admission to care given and equipment provided was carried out for a number of residents. Staff records and relevant records relating to the management of the home were examined. The majority of the records were in order, there were gaps in relation to 1 set of care plans, staff supervision records, induction records for a new member of staff and the lack of evidence of a robust quality assurance system. All of the residents spoken with were happy with the care they receive, one lady said, “that staff were kind to her” and another said “she liked her room and enjoyed living at the home”. Staff were also positive and said they enjoyed working at the home. One inspector sat with residents and sampled the midday meal which was satisfactory. The Commission met with the Providers Mr and Mrs Kassam in September 2005 to express concerns about the time it was taking for outstanding requirements related to the environment and the health and safety of residents to me met. An action plan to improve the environment and protect residents was submitted by Mrs Kassam. This is being monitored, however due to length of time these requirements have been outstanding the Commission will be asking for completion dates for outstanding works. Requirements made by The Fire Service are still outstanding. One issue of serious concern relating to the unsafe administration of medication was identified during the inspection. An immediate requirement was made and a letter of serious concern sent to Mrs Kassam. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Medicines should only be administered to residents by a qualified nurse or general practitioner; care staff must not on any account administer medication. All residents must have a care plan compiled to inform staff how to meet their needs. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 7 The overall appearance of the building from the outside is that it is in need of maintenance and upgrading. Furniture in some bedrooms look tired and some bedrooms have unpleasant odours and carpets in some of the resident’s bedrooms look dirty and are stained. There remains some uncovered radiators which pose a risk to residents of burning. The home does not comply with requirements of the fire service although Inspectors were told that work is underway. The home still does not have robust quality assurance, monitoring and development system. The staff induction procedure needs to be reviewed to ensure all staff have the appropriate induction for their role and to protect residents. Staff who have been employed following a satisfactory POVA first check must not work unsupervised until their CRB disclosure is returned. 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. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 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 Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to visit the home to ensure that the home is able to meet their needs. The home’s assessment procedure is adequate; risk assessments are completed once residents are admitted. All residents have a contract. The statement of purpose/service user guide available was not up to date. EVIDENCE: The Statement of Purpose/Service User Guide which is available in the hallway of the home did not include the last inspection report; the one enclosed was for June 05. The fees at the home range between £550- £700 per week. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 10 The records of 5 residents admitted since the last inspection were examined and case tracked and the outcome for these standards are that all new residents have assessments completed. Residents spoken with did not remember having the information before admission but thought their relatives might have. Pre assessments are carried out and were seen and assessments had been compiled with appropriate risk assessments following admission, these had been updated, all resident’s records seen had a contract with terms and conditions enclosed. Residents and their relatives do have to opportunity to visit the home before making a decision. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The majority of residents have up to date care plans which instruct staff how to meet their needs, the staff meets the majority of their health needs. Privacy and dignity are respected in the home. The medication administration procedures in the home are not safe and do not protect residents. EVIDENCE: 5 new residents records were tracked all had assessments, 4 had care plans but I did not, all had risk assessments consisting of manual handling, pressure areas, nutrition and falls related to identified needs. These had been updated. Weights and baseline observations are carried out and updated. Daily records are made, Dr’s and other professional’s visits recorded. Accident book seen and entries had been made appropriately. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 12 Staff were noted to knock on doors and speak to residents respectfully. Residents being nursed in bed looked clean and comfortable and all residents looked well cared for. One inspector observed part of a medication round being undertaken, the drugs trolley was wheeled into the dining room where it was noted by both inspectors that carers were coming up to the trolley to get drugs in containers to take to other areas of the home unsupervised where residents were having lunch in their rooms. The nurse administering the drugs gave 4 carers drugs in containers to take away and administer unsupervised. One of these carers was undergoing induction but was working on her own. The Inspector asked the qualified nurse to immediately stop the drug round, the nurse was told her she was in breach of NMC and CSCI legislation. The reply was that as they only had one drugs trolley and as residents needed their medication with their lunch this was the usual practice. A new medication procedure dated 9/2/06 had been sent with the PIQ, which said “Medication should be administered by a registered first level nurse or by a designated, appropriately trained member of staff”. The procedure states staff should carefully check the identity of each resident to ensure that the correct record is being used and the correct medication is being given to the correct person. Also that “ The trained nurse in charge of the shift is responsible for administering the required medication to each resident according to their MAR chart”. This procedure was not being followed. An immediate requirement was made and a form left at the home. A letter of serious concern was then sent to Mrs Kassam. CSCI has now received a letter from the home to say all staff nurses have been made aware of the change, this does indicate that this unsafe practice has been going on at the home. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents that are able are encouraged to maintain contact with their family and friends so that they can satisfy their social and emotional needs. The social activity programme is flexible to cater for individual residents abilities and to offer variation to daily living. Those residents who are able, are encouraged to exercise choices within their lives. The standard of food is adequate, offering choice and variety. EVIDENCE: When the inspectors arrived at the home six residents were in the lounge and others were either being assisted by staff to get up or were having a lie in bed. One of the residents in the lounge was knitting. One resident visited in the privacy of their room spoke about the ability to keep themselves to them self without feeling pressurised into mixing with the Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 14 other residents. This resident liked to do tapestry and commented that occasionally went to the dining room to eat lunch. At lunch time two residents spoke about the poetry reading sessions, the painting group and occasional musical evenings. Residents spoken with felt that their relatives and friends are made welcome at the home and most said that they could see their visitors in the privacy of their own rooms. The visitors book records frequent visitors to the home. An inspector joined residents for the main meal of the day in the dining room. The meal was chicken curry, rice, potatoes and peas. Residents were heard to comment about the strange combination and one resident sent their meal back asking for just the curry and rice. An alternative of omelette and salad was chosen by a few of the residents. The majority of residents seemed to enjoy their meal and staff were observed to assist those who were having difficulty using the utensils. Dessert was a choice of either egg custard or strawberry whip. The home has a four weekly rotating menu, which shows a variety of main meals and suppers throughout each week. Food stocks at the home were plentiful, with fresh fruit available. On the day of the visit there were little fresh vegetables in stock but evidence of frozen vegetables was observed. Details of likes and dislikes of food are on display in the kitchen along with information about the special diets required by some residents. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and investigated. Although the majority of staff are trained to recognise abuse and report according to procedure, but supervision of new staff is inadequate and may not protect residents from abuse. EVIDENCE: Complaints are recorded; they were minor concerns mainly about the environment. They were all partially substantiated. All have been acknowledged within 28 days according to procedure. 4 out of 5 new staff had received training in adult protection; 1 who had no induction records was not on duty so training could not be confirmed. There was also a lack of supervision records for carers who have POVA first and who are awaiting CRB, on the day of the fieldwork one carer awaiting CRB was seen caring for residents unsupervised. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 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): 19,20,21,22,23,24,25,26 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is slowly being improved but some areas are not safe or well maintained. Not all residents’ rooms are clean or safe. Adequate communal space is available, and toilet and washing facilities meet the needs of residents. Aids and equipment are available to promote independence. EVIDENCE: During this visit inspectors carried out a full tour of the home visiting all communal and private accommodation used by residents. The overall appearance of the building from the outside is that it is in need of maintenance and upgrading, the long driveway to the home is in poor condition. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 17 On going improvements to accommodation are making the home begin to look more homely and comfortable. Bathrooms and toilets in use have aids and adaptations so that residents can maximise their independence. Furniture in some bedrooms look tired and some bedrooms have unpleasant odours. The communal lounges were adequate although some furniture is looking worn and in need of replacement. The lounge looks out onto the rear gardens and patio area which residents have access to. The Inspectors asked for a chair which was in poor condition to be removed from the communal area. There are two dining areas, which were both used at lunchtime. One has a washable floor covering but the carpet in the other was very dirty and in need of commercial cleaning or replacement. The majority of bedrooms visited were basic although some rooms, which residents and families had taken the time to personalise, looked more homely. Staff told the inspectors that bedrooms are being redecorated and upgraded as they become vacant. A sample of these rooms were observed to be of a better standard and more comfortable and fresh looking. There remain a number of shared bedrooms. One resident commented that it wasn’t their choice to share and that she would like to have her own room. This was discussed with the nurse in charge at the conclusion of the visit. Two areas of the home had an unpleasant odour and this matter was brought to the attention of the nurse in charge. Carpets in two bedrooms were in need of cleaning or replacement and staff commented that there had been a request to the providers for a new carpet cleaner. It was observed that some radiators remain uncovered in bedrooms and a number of bathrooms, which could put residents at risk from burning. Laundry facilities are adequate. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 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): 27,28,29,30. The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the numbers of staff on duty, but the Targets for Vocational Qualifications of care staff have not yet been met. Staff training provision at the home has improved. Residents are not supported or protected by the homes recruitment policy and practices. Due to the lack of supervision of new staff until their Criminal Record Bureau Disclosures are received. EVIDENCE: National Vocational Qualifications (NVQ) targets have not be met by the home by the target date of December 2005. Information provided by the manager prior to the visit confirmed that thirty six percent of carers have an NVQ and three other carers are currently undertaking the qualification. Training records show that mandatory training has taken place for the majority of staff, such as Fire training, Protection of Vulnerable Adults and First Aid. At the last inspection it was noted that a number of overseas staff did not have adequate English language skills. The Inspectors were told that some staff are now accessing training through their church at their own cost. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 19 The duty rotas have been changed so that more staff are on duty in the early morning to improve outcomes for residents. Residents who could offer an opinion said they thought there were enough staff on duty and did not say that it affected their choices, although the majority of residents could not offer an opinion. The records of 5 new staff were seen and all contained POVA first, only 3 had CRB and there were no supervision records for those with just POVA. 3 new staff had induction records, 1 did not and the other for a qualified nurse had not been completed although she started in Feb 06. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 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): 31,32,33,35,36,37,38. The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered manager is qualified and competent to run the home and regular Regulation 26 reports on the conduct of the care home are sent to CSCI. The views of residents, their families and friends are sought but these have yet to be used to measure how successful the home is at meeting its aims and objectives and the statement of purpose of the home. Residents or their representatives manage any financial affairs. The procedures for supervision of staff have not been implemented so that staff have not had opportunities to regularly discuss their practice and improvements to the service. Some practices do not promote and safeguard the health and safety of residents living at the home. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 21 EVIDENCE: Quality assurance questionnaires have been returned from a number of residents or their representatives to the provider and these were observed to cover: Catering and food, personal care, daily living, premises and management. In general the majority of relatives were either satisfied or quite satisfied with the service. No qualitative action has yet been taken to measure the service to establish if the home is being run in the best interests of residents. Formal supervision systems have been agreed and the formats for recording supervision were observed during the visit, but it was confirmed by staff that the systems are only just being put in place. Other care staff spoken with confirmed that they knew who was their supervisor was and that they are supervised as part of their normal daily working practice. The requirement for new staff to be supervised until CRB disclosures are returned even if POVA first is satisfactory was discussed during the visit. The majority of the health safety and welfare procedures do protect residents but the unsafe medication administration procedure in the home and the delay in guarding radiators and pipe work does affect the health and safety of residents. Some radiators and pipe work in bathrooms and bedrooms remain uncovered which could put residents at risk from burning. CSCI has been informed that risk assessments have been carried out on all unguarded radiators and pipe work, however Mrs Kassam is aware from requirements on inspection reports and in discussion that radiators and pipe work must all be covered. Requirements made by the Fire service are still outstanding although Inspectors were informed that work is ongoing. It was brought to the attention of the nurse in charge that the area out side one bedroom had loose tiles which were a trip hazard and that the fire escape leading from this area at the time of the visit was a slip hazard if leaves became wet and the escape route had to be used. Mrs Kassam will be asked to submit a new plan to establish completion dates for all outstanding requirements. Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 2 2 2 2 2 2 2 STAFFING Standard No Score 27 2 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 1 2 1 Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 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. Standard OP7 Regulation 15 Requirement Timescale for action 30/06/06 2. OP9 13 (2) 3. OP19 23 (4) 4. OP19 23 (2) b The registered person shall prepare a written plan as to how service user’s needs in respect of his health and welfare are to be met. CSCI to have written confirmation of action taken by 16/05/06 Medicines, including controlled drugs, for service users receiving nursing care must be administered by a medical practitioner or a registered nurse. An immediate requirement was made during the fieldwork that carers must not administer medication and CSCI were to be informed of action taken in writing within 7 days. A letter was received. The registered person shall 30/06/06 ensure that the building complies with the requirements of the local fire service. CSCI to have written confirmation of action taken by The registered person shall 30/06/06 ensure that the premises are kept in a good state of repair DS0000024231.V290221.R01.S.doc Version 5.1 Truscott Manor Page 24 externally and internally. CSCI to be sent a new action plan stating completion dates for all outstanding works and an annual development plan for 2006/2007 for planned improvements to the premises. 5. OP25 13 (4) a 6. OP25 23 (2) d 7. OP29 18 8. OP33 24 9. OP30 18 The registered person shall ensure that pipe work and radiators are guarded or have guaranteed low temperature surfaces. CSCI to be informed of a final date when all radiators and pipe work will be covered. The registered person shall ensure all parts of the home are kept clean. CSCI to have written confirmation of action taken by The registered person shall ensure that persons working at the care home are appropriately supervised. CSCI to have written confirmation of action taken by The registered person shall establish and maintain an effective quality assurance and monitoring system, reviewed at appropriate intervals for improving the quality of care provided at the home. The registered person shall supply to the Commission a report in respect of any review. CSCI to have written confirmation of action taken by The registered person shall ensure that all staff receive induction and foundation training. CSCI to have written confirmation of action taken by DS0000024231.V290221.R01.S.doc 30/06/06 30/06/06 30/06/06 30/06/06 30/06/06 Truscott Manor Version 5.1 Page 25 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 Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Truscott Manor DS0000024231.V290221.R01.S.doc Version 5.1 Page 27 - 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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