Inspection on 25/01/06 for Victoria House Care Home

This inspection was carried out on 25th January 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

Victoria House Care Home 14/08/08

Victoria House Care Home 15/08/07

Victoria House Care Home 06/06/06

Victoria House Care Home 01/07/05

Victoria House Care Home 17/02/05

Victoria House Care Home 28/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

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 Victoria House 71-73 Victoria Road Polegate East Sussex BN26 6BX Lead Inspector Gwyneth Bryant Unannounced Inspection 25th January 2006 08:00 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 Victoria House DS0000021277.V263342.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. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Victoria House Address 71-73 Victoria Road Polegate East Sussex BN26 6BX 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) 01323 487178 01323 487178 Supreme Care UK Limited Mrs Esther Redmond Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty (20). That service users must be older people aged sixty-five (65) years or over on admission. 1st July 2005 Date of last inspection Brief Description of the Service: Victoria House is registered to care and accommodation for up to twenty older people. The home is a three-storey detached property situated in a residential area of Polegate. It is located in close proximity to local amenities including bus and rail links. Service users accommodation consists of twenty single rooms, eleven of which have en-suite facilities. All bedrooms have at least a wash hand basin. The home has a range of communal areas including a large lounge and dining area. There a two communal bathrooms, both of which are assisted, and four communal toilets. There are toilet riser seats and handrails fitted as required. The external grounds offer an attractive garden and patio area. Car parking is available at the front of the property. The home has a passenger lift and a series of ramps that enable service users to access all parts of the home, however there are some internal steps so service users on the upper floors need to be mobile. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over two days on 25 January lasting for 2.45 hours and on 2 February lasting for 4.45 hours. It was necessary to inspect on a second day as the Registered Manager was on leave on 25 January and a number of records were not available for inspection in her absence. There were eighteen service users in residence on the days of which six were spoken with. The purpose of the inspection was to check compliance with the requirements made during the last inspection and to inspect other standards. The Manager, a senior carer, one member of care staff and the cook were spoken with. It was not possible to access all records on the first day but over the two days a range of documentation was accessed and viewed including service users care plans, personnel files and medication records. A tour of the premises was carried out. Immediate Requirements were issued in respect of increasing staffing levels, reassessing service users who may be out of category, testing of portable appliances, leaking radiators to be fixed and no staff to work in the home without a Criminal Records Bureau check. This is the second inspection of this year and therefore this report should be read in conjunction with the report from the unannounced inspection carried out on 1 July 2005. What the service does well: What has improved since the last inspection? The Manager has almost finished updating the homes Statement of Purpose and Service Users Guide but in the interim has a checklist to ensure prospective service users receive up to date information on services provided. A great deal of work has been carried out to ensure service users care plans are detailed and clearly direct staff in the delivery of care. Care plans are regularly reviewed to ensure changes in care needs are recorded and met. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 6 Staff have been trained in manual handling and the Control of Substances Hazardous to Health. Systems have been created to ensure CSCI is notified of incidents of disease. 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. Victoria House DS0000021277.V263342.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 Victoria House DS0000021277.V263342.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): 1, 2, 3 and 4 Service users are supplied with up-to-date information about the services provided by the home to enable them to make an informed as to whether or not the home is suitable for them. Pre-admission assessments need to be more robust to ensure that only service users within the homes registration category are admitted. EVIDENCE: The Manager has almost finished work on updating the Statement of Purpose and Service Users Guide, however she ensures prospective service users have detailed information on services provided at Victoria House. A sample of pre-admission documents were viewed and while it is evident that the manager identifies care needs two service users admitted appear to be out of the homes’ registration category. The home has been required to ensure these two service users are reassessed without delay. Pre-admission documents are used effectively to create a detailed care plan for each service user. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 9 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 and 11. Standard 6 is not applicable The content of the care planning system is consistent and provides staff with most of the information they need to satisfactorily meet service users’ needs. Service users are protected by satisfactory systems for the recording, handling and storing of medication. Service users would be better protected if risk assessments included the management of the risk. EVIDENCE: A sample of care plans were viewed and found to be detailed and clearly identify most aspects of service users’ care needs, such as managing challenging behaviour, assisting those with significant sight loss and those diagnosed as carriers of MRSA. It is evident that pre-admission information is used effectively in the formation of care plans. However, some shortfalls were identified in that risk assessments need to be expanded to include how the risk is to be managed to ensure staff provide consistent care. The home maintains detailed notes that are used to inform the care plan reviews; however not all care plans had been reviewed monthly. This may result in staff being unaware of changes in care needs, thus putting service users at risk. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 10 Not all care plans included a photograph of the service user and this needs to be addressed to facilitate identification by other professionals. Care plans showed that one service user needed two carers for all transfers but the home does not have a suitable lifting device for this person. In addition the risk assessment for tissue breakdown for this person does not include the management of the risk such as the maintenance of turning charts. Care plans and daily notes showed that another service user had displayed erratic behaviours that impinged on the comfort and welfare of other service users. Service users spoken with mentioned that while they understand that the mental condition of some service users had deteriorated they did feel that their behaviours were disruptive. The home was required to seek an urgent reassessment of these service users. When service users are noted to have lost/gained weight, care plans need to include actions to be taken to address this. The homes’ bathroom scales were found to be set above zero, thus readings would be inaccurate Medication records and storage arrangements were viewed and both aspects were satisfactory, ensuring service users are not at risk. Medication administration charts were up to date, accurate and clear. All staff who administer medication have received adequate training and staff spoken with were able to describe how medication is handled safely. Staff were observed to treat service users with consideration and respect and those service users spoken with spoke positively of the care and kindness of staff. All mentioned the Manager and praised her for the consideration she gives to all service users and that she listens to them. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 11 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 and 15 The arrangements for the in-house leisure and social activities need to be based on service users preferences to provide opportunity for mental and physical stimulation and promote independence and choice. Service users benefit from well-balanced and nutritious meals but could be improved with the introduction of choice. EVIDENCE: The home has a weekly programme of suitable activities, including cards, board games, music and exercise. However, during discussion with the Manager it was found that service users are charged extra for the provision of in-house activities. The Registered Provider has been required to cease this practice as activities should be provided within the set fees. The meals looked appetising and were attractively presented. All residents spoken with were positive and complementary about the food. However, alternatives are not offered for each meal although the cook said she is happy to provide alternatives if asked. Alternative should be offered at each mealtime to ensure service users have a choice each day. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 12 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 Systems are in place to ensure all complaints could be satisfactorily addressed. Staff training ensures that service users are protected from abuse. EVIDENCE: There have been no complaints since the last inspection. Appropriate policies and procedures are in place to demonstrate that complaints are recorded and include actions taken to address any issues. The home has policies and procedures on adult protection and all staff have been trained in adult protection including types of abuse, what action should be taken if staff have any concerns, and whistle blowing. Staff training records confirmed they had received this training and staff spoken with were aware of the correct procedures. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 13 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, 21, 22, 24, 25 and 26 Service users’ benefit from an environment which provides choice of space and privacy, however, a number of maintenance issues impact on both safety and comfort including, provision of bathing facilities and of suitable aids and adaptations to create a pleasing, safe and comfortable environment for service users to live in. EVIDENCE: A tour of the premises was carried out and service users bedrooms were tastefully decorated and many have taken the opportunity to personalise their rooms with pictures and ornaments. Not all service users bedrooms contained all the furniture as required under the Standard and this is unacceptable. The provision of furniture should be decided on an individual basis and subject to risk assessments. Generally the home is clean but there was an offensive odour in one bedroom and a number of maintenance shortfalls were identified. The bathroom scales were so badly rusted the floor had been stained with rust. Not all communal toilet facilities had wash hand basins fitted and this needs to be addressed to reduce the risk of infection. All staff need to have updated training in infection control. Not all staff used aprons and gloves while Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 14 providing personal care, neither did all staff change gloves and aprons when going to a different room. A used incontinence pad had been left on the carpet outside a service users room, posing a risk of cross infection and an unpleasant odour on the stairway. Discussion with staff found that they had not been trained in infection control procedures and this must be rectified. Grab rails and toilet riser seats had been fitted for individuals but a suitably qualified person needs to make an assessment of the premises and grounds to ensure the needs of all service users’ are met. A number of call bells in service users’ bedrooms were either missing or inaccessible and this must be rectified to ensure service users are able to call for help in an emergency. Some service users’ dependency levels have increased significantly therefore a suitable lifting device to enable staff to safely lift service users needs to be provided. On the first day of the inspection there was a problem with the central heating resulting in some parts of the home being cold. An immediate requirement was issued in respect of this. In addition it was found that service users are unable to control the heating in their own rooms and this must be rectified to ensure service users personal accommodation is at a temperature they choose. Also a number of radiators in service users bedrooms were leaking posing a risk of damage to service users possessions and making the rooms’ atmosphere damp. An immediate requirement was issued in respect of this. The ground floor bathroom was still being used for storage and this practice must cease to ensure there are sufficient bathing facilities to meet service users needs. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 15 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 deployment and number of staff at key times is insufficient to meet service users care needs. Recruitment practices are not robust and do not provide safeguards to protect service users Staff would benefit from appropriate training at all levels to ensure that they have the skills and competencies to fulfil their roles. EVIDENCE: Staff rotas were viewed and found that a total of 308 care hours per week are provided by care staff. Staff are also required to serve meals, make drinks and breakfast for service users. The Residential Forum staffing tool recommends a minimum of 508 care hours be provided for the eighteen service users taking into consideration their dependency levels and the layout of the home. Cooks and domestic staff are also employed. As identified under Standard 7, one service user needs two carers for all transfers, thus while her needs are being met there is just one carer to care for the other 17 service users during the day hours. As there is only one carer on duty at night the care needs of this service user cannot be met. Staffing levels need to be increased to ensure the needs of all service users are fully met during both the day and night hours. An immediate requirement was issued in respect of this. On inspection of staff recruitment files it was apparent that the required level of documentation was not in place for the staff that had been recently recruited. For two staff members, there were gaps in employment histories, Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 16 not all staff had provided proof of qualifications and although POVA checks had been obtained for all staff, two had not provided a Criminal Records Bureau check. These practices are unacceptable and put service users at risk. Staff are expected to pay for their Criminal Records Bureau checks so this may account for the lack of these documents, however the Registered Provider remains responsible for ensuring they are carried out. These two staff were recorded as working supervised but there was insufficient staff to ensure they were not left alone with service users. An immediate requirement was left in respect of this. The home has induction and foundation training programmes that meet the Care Skills Sector specifications and there was evidence that staff received both parts of the training. Of a total of fourteen care staff only one has achieved an NVQ qualification in care. One other member of staff has a Certificate in Health and Social Care. Therefore the required level of 50 of care staff with an NVQ qualification remains unmet and a plan must be created to demonstrate how this standard will be met. The Manager explained that she is not privy to staff training budgets so finds it difficult to plan staff training in line with staff rotas. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 17 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, 36 and 38 The Manager provides good leadership and clear direction to staff, thus service users benefit from a well supported staff team. Formal quality assurance and quality monitoring systems need to be created and implemented to enable the Provider to objectively evaluate the service and ensure it is run is service users best interests. There are systems in place do not safeguard all aspects of the health, safety and welfare of service users . EVIDENCE: The Manager has recently completed the NVQ 4 in Care and the Registered Managers award thus ensuring she has the required qualifications to meet the Standard. In addition she has many years experience in the care industry and is familiar with the needs of older people. The ethos of the home is open and relaxed and staff were noted to be comfortable in approaching the manager with any queries. Service users Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 18 spoken with said they would be happy to speak to staff or the manager on any issue. Minutes of staff and service users meetings were viewed and from these it is evident that both groups are given the opportunity to comment on and influence how the home is run. Discussion with the Manager established that she undertakes ‘hands on’ care tasks at each afternoon shift for a total of 20 hours per week. This seriously impinges on her management time. This needs to be addressed to ensure she has sufficient time to undertake all management tasks. Service users surveys are carried out and this quality monitoring system needs to be extended to families and friends of service users. In addition the Registered Provider under takes monthly visits as part of the quality monitoring system. However, the introduction of formal quality assurance and quality monitoring systems would enable to the provider to critically evaluate the service and ensure it is run in the service best interest. Service users spoken with said they liked the service users meetings, as they felt listened to. It was from the minutes of service users meetings that the additional charge for in-house activities came to light. Staff were observed to have good rapport with service users and were knowledgeable about their needs. Staff supervision records were examined and from these it is clear that these sessions identify training needs and good practice issues. The staff member spoken with confirmed she receives satisfactory supervision and was able to outline the areas covered during these sessions. She confirmed that she had received induction but still needs training in infection control. Documents relating to safe working practices and Health and Safety were available and found to be satisfactory as were accident records. There were records showing the regular testing of call bells, emergency lighting and fire alarms and that fire equipment and systems are regularly serviced. On the first day of the inspection a number of service users bedroom doors were wedged open with furniture. In the event of fire this practice puts service users at risk. Suitable closing devices need to be fitted if service users require their bedroom doors to be left open. Staff training in fire safety and infection control needs to be updated. There was a portable radiator in the home that had not been tested as being safe. An immediate requirement was issued in respect of this. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 19 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 X 2 2 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X 3 3 X 2 Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 20 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 OP4 OP7 Regulation 12(1)(ab) 14 (1)(d) 13(4bc) Requirement All service users potentially out of the homes registration category must be reassessed. Risk assessments must be expanded to include the management of the risk for service users within and outside the home. All care plans need to include a photograph of the service user. Appropriate action needs to be taken where service users are noted to have lost or gained weight as required under Reg 17 (1a) Schedule 3(o). (timescale of 1/10/05 not met) That a planned programme of activities be devised and paid for by the Registered Provider. That all parts of the home are properly maintained and all repairs undertaken as necessary. The ground floor bathroom needs to be made available for use. (timescale of 1/10/05 not met) That suitable and accurate equipment is provided for weighing service users. DS0000021277.V263342.R01.S.doc Timescale for action 16/02/06 31/03/06 3 4 OP7 OP8 Schedule 3(2) 14 (1a) (2ab) 31/03/06 31/03/06 5 6 7 OP12 OP19 OP21 16 (2mn) 23(1a) (2b) 23(2j) 14/02/06 31/03/06 31/03/06 8 OP22 23(2n) 31/03/06 Victoria House Version 5.0 Page 21 9 OP22 16(1)(2c) 23(2n) 10 11 12 13 OP24 OP25 OP25 OP26 14 OP26 15 16 17 OP26 OP26 OP27 18 19 OP28 OP29 20 OP31 21 OP33 22 OP38 An assessment of the premises needs to be undertaken by a suitably qualified person to ensure the needs of all service users are met. (timescale of 1/10/05 not met) 16(1)(2c) That furniture listed under the standard be provided in service users bedrooms. 23(1a) That all leaking radiators are (2ap) repaired. 23(1)(2p) That heating can be controlled in service users bedrooms. 16(2j) That hand wash handbasins be 13(3) fitted to all communal toilet facilities that require them. (timescale of 1/10/05 not met) 23(1d) That high standards of 16(2jk) cleanliness are maintained throughout the home, including the elimination of offensive odours. 13(3)18 That all staff are trained in (1a) infection control. 13 (3) That staff use protective aprons and gloves when delivering care to service users. 18 (1) (a) Staffing levels need to be increased to ensure service users needs are met. (timescale of 1/10/05 not met) 18(1)(a-c) That a plan is developed to (i) ensure 50 of staff achieve NVQ level 2. 19(4)(a-c) That all staff provide the required documentation prior to appointment, including Criminal Records Bureau checks. 9(1)(2bi) That the Managers management 12(1b) hours be increased to enable her to fulfil her management duties. (timescale of 1/10/05 not met). 24(1ab) That formal quality monitoring (2)(3) and quality assurance systems be created and implemented. (timescale of 1/10/05 not met) 23 (4ac) That the use of wedging open DS0000021277.V263342.R01.S.doc 31/03/06 31/03/06 09/02/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 09/02/06 31/03/06 31/03/06 31/03/06 31/03/06 28/02/06 Page 22 Victoria House Version 5.0 (i)(v) 23 24 25 OP38 OP38 OP38 13 (5) 23(4)(ae) 13(4c) doors with furniture ceases and appropriate door closing devices provided. (timescale of 1/07/05 not met) That a hoist be purchased to enable staff to safely lift service users. That staff training in fire safety be updated. That all electrical equipment be tested before use. 31/03/06 31/03/06 02/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP12 OP15 Good Practice Recommendations That training on the provision of activities is sought for care staff. That an alternate meal is routinely offered each day and included on the weekly menu. Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Victoria House DS0000021277.V263342.R01.S.doc Version 5.0 Page 24 - 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. 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