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Inspection on 24/02/06 for Welcome Care Home Ltd

Also see our care home review for Welcome Care Home Ltd for more information

This inspection was carried out on 24th February 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home`s manager is very experienced, and well qualified, and has daily contact with all service users. The home responds well to requests to improve the service offered and service users say that they can speak with the manager or any of the staff when they want something or are concerned. Needs assessments for service users are very comprehensive and the changes are being made to the planning system to make sure that each service users is able to do the things they like to do. To help this happen there are now individual weekly written plans for all service users that are developing and improving. A group of service users said they are happy with the improvements, and are able to tell staff what they want to do, and "They do listen". Religious needs are catered for and the manager often takes people to church and attends the coffee gathering afterwards. Other activities are offered such as bingo, social centre visits (St Lawrence Hall, and the Davenport Club). Service users are supported to be independent in going out in the local area and many do so. Food is good, and six service users said that they always have what they want to eat. The home is clean, and well maintained, and reflects the decorative tastes of the people who live there. Health and safety is well managed, with no injuries to staff or service users recorded.

What has improved since the last inspection?

Service users care plans are now consistently reviewed each month, and a number of service users said they are involved in doing this. All service users are now well informed about the medication they are given, and medication is well managed. The staff are now better informed about how to protect service users, and the home`s Adult Protection policy has been reviewed. Staff are fully informed in how to manage complaints, and this policy has also been reviewed. The information about how staff are recruited, and about individual staff histories, and police checks, has improved. Good checks are being done and records are being kept. Staff supervision has improved and meetings now happen at least every two months for all staff.

What the care home could do better:

There should be more details of each service users individual activities entered on their weekly activities plan to help make sure these happen consistently. Some of these plans only show a few activities, although it is clear that more activities do happen. Care plans should have a bit more information about service users individual abilities, especially in carrying out personal care in order to maintain and increase their independence. All service users need to be assessed about whether they can and want to take their own medication, and this should be recorded in care plans. The homes complaints policy must have a specific timescale for investigating complaints included. The way the home consults with service users needs to be improved and the views of service users must be included in plans for improving the service offered. There needs to be an audit of the home done at least once a year to make sure that all necessary improvements are planned for. There needs to be a written log of repairs needed, and completed, showing how long it takes to carry out repairs. Although there are not any concerns at the moment, the system for recording money kept on behalf of service users needs to be improved, to better safeguard their interests.

CARE HOMES FOR OLDER PEOPLE Welcome Care Home Ltd 26-28 Fordel Road Catford London SE6 1XP Lead Inspector Sean Healy Unannounced Inspection 24th February 2006 09:30 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 Welcome Care Home Ltd DS0000025650.V281740.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. Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Welcome Care Home Ltd Address 26-28 Fordel Road Catford London SE6 1XP 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) 020 8697 5024 Mrs Margaret Newland Mrs Margaret Newland Care Home 15 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0) Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 15 persons whose primary needs are old age and dementia 4th November 2005 Date of last inspection Brief Description of the Service: The Welcome Care Home provides personal care and accommodation for a maximum of 15 older people. The overall aim is that of offering care and support, in a homely environment, trying to create a happy and relaxed family atmosphere. The underlying philosophy, stated in the home’s brochure, is that of a holistic approach to care. The registered provider is a company belonging to Mrs Margaret Newland, who is in day-to-day control of the home. A deputy manager assists her, and the team consists of 11 care staff, a mixture of men and women, from a variety of cultural backgrounds. The home was opened in 1993 and consists of two semi-detached Victorian houses, which have been joined into one. There is a rear garden with a patio, a fishpond and a lawned area, which is well maintained. Thirteen of the home’s bedrooms are single with en-suite toilet facilities. There is one shared room, which has a wash hand basin only, but exclusive use of a nearby toilet. There is a passenger lift and a short stair lift to ensure access to all parts of the house. The home is situated in a quiet side road in the Catford area, with some local shops nearby. The centre of Catford, where there are public transport (buses and trains), other civic amenities and shops, is about one mile away. Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, and took place over one day. It was facilitated by the registered manager and assistant manager. Two staff were interviewed. A group of service six users gave their views of the home, and three separate service users also contributed individually. There were three service user vacancies. What the service does well: What has improved since the last inspection? Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 6 Service users care plans are now consistently reviewed each month, and a number of service users said they are involved in doing this. All service users are now well informed about the medication they are given, and medication is well managed. The staff are now better informed about how to protect service users, and the home’s Adult Protection policy has been reviewed. Staff are fully informed in how to manage complaints, and this policy has also been reviewed. The information about how staff are recruited, and about individual staff histories, and police checks, has improved. Good checks are being done and records are being kept. Staff supervision has improved and meetings now happen at least every two months for all staff. What they could do better: There should be more details of each service users individual activities entered on their weekly activities plan to help make sure these happen consistently. Some of these plans only show a few activities, although it is clear that more activities do happen. Care plans should have a bit more information about service users individual abilities, especially in carrying out personal care in order to maintain and increase their independence. All service users need to be assessed about whether they can and want to take their own medication, and this should be recorded in care plans. The homes complaints policy must have a specific timescale for investigating complaints included. The way the home consults with service users needs to be improved and the views of service users must be included in plans for improving the service offered. There needs to be an audit of the home done at least once a year to make sure that all necessary improvements are planned for. There needs to be a written log of repairs needed, and completed, showing how long it takes to carry out repairs. Although there are not any concerns at the moment, the system for recording money kept on behalf of service users needs to be improved, to better safeguard their interests. Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 7 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. Welcome Care Home Ltd DS0000025650.V281740.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 Welcome Care Home Ltd DS0000025650.V281740.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): 3, 5 and 6 All service users needs are assessed before moving into the home, and plans are made for meeting these needs with service users. Prospective service users have complete information they need to make an informed choice about where they live. Intermediate care is not provided. EVIDENCE: The homes manager, who is a Registered General Nurse, together with the assistant team manager, carries out assessments on all service users needs before accepting their referral to the home. A comprehensive assessments system is used, and this is supported by a social service written assessment of need. These assessments include all areas of health care needs, mental health care including emotional support needs, and social and leisure care needs. Good records are maintained and families and service users are involved in providing information for these assessments. These are then used to develop detailed plans for providing care within the home. Regarding trial visits to the home prior to moving in, there is evidence, from discussion with service users and the provider, that the policy and practices of the home had not changed, and allow good opportunity for service users to Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 10 “test drive” the home before deciding to move in. Wherever possible service users were encouraged to visit before moving in. Staff also go to see service users in their own homes, particularly when users were not able to visit. Three service users said that they “Had been able to visit the home before moving in, and were helped by their families to look at the home, and to ask lots of questions”. The home does not provide for intermediate care or emergency admissions. Welcome Care Home Ltd DS0000025650.V281740.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 and 9 The home ensures that service users health, personal and social care needs are set out in an individual care plan and that health care needs are fully met. Service users are not properly assessed or supported regarding their ability to manage their own medication, but are otherwise protected by the homes medication policy and procedures. EVIDENCE: There are individual care assessments that provide the basis for the care to be delivered. These include risk assessments. Care plans are drawn with the involvement of the service users, and their families where appropriate, and they are reviewed every month, and more often when needed. Service users’ files show that service users’ health, and personal needs are included in the care plan. It is recommended that care plans include more clear information about service users individual abilities, especially in the area of personal care, in order to maintain independence for service users. This could easily be done by drawing up a do’s and don’t list in relation to each service user for staff to follow. (Refer to Recommendations OP7) Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 12 Details of who is involved in monthly review meetings, and what is agreed at these meetings are clearly recorded in detail. These records are currently kept together in a file for all service users, and it is recommended that each service users own record be kept on their own individual file, to ensure better confidentiality and ease of access for service users. (Refer to Recommendations OP7) The home has done a good deal of work in compiling information on each service users social and leisure care needs and revised the care plan format to include these. Weekly individual plans are now in place to help ensure that staff are aware of activities for each service user, and when to offer support. These activities include: reading, watching favourite TV programmes, outings to places such as church meetings or a social club, and group activities in the home such as exercise sessions. Some of these weekly plans are comprehensive, but some do need more activities included. (Refer to Recommendations OP7) The homes manager has now spoken with relevant staff, who had been giving medication to a particular service user mixed in with their food, without a formal agreement being in place to do this. The manager was unaware that this was happening and this practice has now been stopped. As was the case at last inspection, the provider said that none of the service users administered their own medications, as none was able to manage this safely. However not all service users assessments are clear on this issue and there is not an agreement on this in all care plans. (Refer to Repeated Requirements OP9) Welcome Care Home Ltd DS0000025650.V281740.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): 13 and 15 Service users maintain contact with their families, friends and community contacts, and receive wholesome and appealing balanced diets, in pleasing surroundings and at suitable times. EVIDENCE: Service users’ files show that activities are planned and recorded, and provides a useful insight into activities that the staff undertook with individuals. There is now a detailed weekly social and leisure activities plan in place for each service user, and a record is kept to ensure activities are offered consistently. These include regular outings in the local community, to visit local cafes, pubs, library, day centre, dancing club, and visits to local churches and places of worship. Some service users visit Church of England churches, while others visit the Jehovah Witness Kingdom Hall regularly. The service users interviewed all said that they get good support from the home in going out, and can have visitors come to the home at any time. Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 14 There us a four weekly rolling menu used which service users said they are consulted on. The provider said that all service users knew that they could ask for alternatives and many did that. Six service users said that: “The food is excellent and staff tell us what is going to be on tomorrows menu and ask if we’d like anything different”. They also confirmed that they can have meals at times that suit them, and ask for something different at any time. The menu on the day included a fish dish, which service users spoken to were very happy with. Welcome Care Home Ltd DS0000025650.V281740.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 and 18 Service users can be confident that their complaints will be acted on and taken seriously, but the policy needs to include some important information to be included. Service users may are protected from abuse by the home’s policy. EVIDENCE: There have been no complaints received since last inspection. All service users spoken to felt that they knew that they could speak to any of the staff, if they had reason to complain, and that the manager is always available to listen to their concerns. The home has a complaints policy, which would benefit from including some more specific information, regarding the homes commitment to finalising any investigations within a 28-day timescale, and with regard to ensuring that all complainants receive a written outcome for their complaint. (Refer to Requirements OP16) The home had an adult protection and a whistle blowing policy and staff receive training on these policies. The provider said that prevention of abuse was discussed regularly with staff at supervision and at team meetings. The homes policy has now been updated, to reflect the local authorities new policy, and staff confirmed that they had received training regarding this policy. It is recommended that a simple guidance sheet for staff to follow (a flowchart) is included at the front of this policy. (Refer to Recommendations OP18) Welcome Care Home Ltd DS0000025650.V281740.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): 19,23 and 26 The service users live in a safe environment, and their own rooms suit their needs, and are comfortable and clean. The home is clean pleasant and hygienic. EVIDENCE: The home is located in a residential street within walking distance of shops and public transport. The proprietor of the home is responsible for routine maintenance in the home, which is generally well decorated and well maintained. To this end a maintenance man is contracted to carry out repairs as necessary. It is recommended that the system for recording repairs and renewals needed is improved to include dates repairs were first reported, dates completed and the quality of repairs carried out, in order to better monitor any problems in carrying out repairs, and to act as a quality assurance mechanism. (Refer to Recommendations OP19) The home benefits from a lift to allow access to floors above ground level. The garden is well maintained and fully accessible. The home has sought guidance from the local Fire Authority as to the suitability of the building and has complied with all requirements. The home and garden is wheelchair Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 17 accessible, but the size of rooms and corridors does not lend itself to comfortably accommodating wheelchair users. Currently there are no wheelchair users resident at the home. All rooms are of an acceptable size are adequate in the provision of facilities such as sinks and furniture. There are thirteen single rooms and one double room, all with an en-suite toilet and sink. Two rooms have also an en-suite shower. All service users said that they are happy with their rooms, which look homely and reflect their own decorative tastes. The home provides each service user with clean comfortable bedrooms, which are well maintained and furnished. Rooms are well ventilated heated with good natural and electric lighting. In the recent past the home has conducted a questionnaire survey with service users regarding how they would like the home and their rooms decorated, and has since decorated some rooms in response to service users wishes. The home is clean and tidy. Service users said that the staff work hard to keep the home clean and well kept. Hand washing facilities are available in all areas where staff might handle infected materials. The laundry is separate from the kitchen and includes sluicing machines. These facilities although small, are satisfactory. There is a cleaner employed and a weekly cleaning rota is used to maintain a high level of cleanliness throughout the home. Welcome Care Home Ltd DS0000025650.V281740.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): 29 Service users are protected by the home’s recruitment policy and practices. EVIDENCE: The home has an adequate recruitment policy, which was last reviewed in February 2006. This policy now reflects the requirement to carry out CRB checks on all staff, but needs some more information about POVA issues for staff, such as checking the POVA register, referrals to the POVA register, and informing staff about POVA and it’s implications. (Refer to Recommendations OP29) All staff files have been updated to include two references, a CRB/POVA check, and information about the applicants work histories including any gaps. A minimum of two staff now carry out the interviews to ensure fairness and reference requests now include a request for information about the referees relationship to the employee, and a request for references to be supported with headed paper or a compliment slip. Each staff member’s file includes a pre-employment checklist, but although it is clear that the information is being taken up prior to employment, this process is not recorded on these checklists, which makes subsequent monitoring of the process more difficult. (Refer to Recommendations OP29) Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 The home is well managed by a manager of good character and experience. The home makes efforts to include service users views in making decisions, but cannot yet demonstrate fully that the home is run in the best interests of service users. Service users financial interests are safeguarded, but improvements are needed in record keeping to better demonstrate this. Staff are appropriately supervised, and health and safety is well managed. EVIDENCE: The homes manager is very experienced and is a qualified nurse and holds an NVQ 4 qualification in care and management. She is supported by and assistant manager who is also a nurse and who knows the service users well as she has worked in the home over a number of years. Service users said they are happy with how the home is run. Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 20 As was the case at the last inspection: there was evidence, that thought has been given to instituting an effective quality assurance system, based on seeking the views of service users. Some service users surveys have been carried out, in relation to food provided and décor, but there is not a means of making service users aware of findings, or a system for using information to formulate a development/improvement plan. There are currently no annual quality audits taking place. Since last inspection the manager has made some progress in developing a system for quality assurance but further action needs to happen to address these issues. (Refer to Repeated Requirement OP33) The home is not responsible for the management of any of the service users benefits or bank accounts and this responsibility lies with either the service users, or their families. However the home does look after small amounts of money for service users for use for paying for hairdressing and other small expenditures. The current system for accounting for this money needs to be improved to ensure that complete records are kept of all money held, and receipts are kept for all money spent. These records should be fully auditable. (Refer to Requirements OP35) The homes management have now started to provide consistent formal supervision for all staff every two months. Written notes are kept on a detailed recording form, and the appraisal system is now also being employed for all staff. The home makes every effort to ensure service users are safe and that the home is well maintained. There are policies on health and safety, and regular training for staff in all related areas such as fire safety, moving and handling, risk assessments, food hygiene and first aid. Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 2 3 X 3 Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 22 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 OP9 Regulation 12.1,2,3 Requirement The registered manager must ensure that all service users abilities and wishes regarding self medication are recorded on their individual care plans and that action is taken to support any individuals who may wish to self medicate. This is a repeat of previous requirement Timescale 31/01/06, partially met. Timescale now revised. Timescale for action 30/04/06 2 OP16 22 3 OP33 24 The registered provider must 30/04/06 include written information in the complaints policy regarding the homes commitment to finalising any investigations within a 28day timescale, and with regard to ensuring that all complainants receive a written outcome for their complaint. The registered provider must put 30/04/06 in place and maintain a system for reviewing and improving the quality of care provided at the home. The system must be based on seeking the views of service users. This is a repeat of a DS0000025650.V281740.R01.S.doc Version 5.1 Page 23 Welcome Care Home Ltd 4 OP35 13.6 previous requirement, Timescale 01/07/05 Unmet, and 28/02/06 partially met. The registered manager must ensure that safeguards are in place to protect the financial interests of the service users, as described in Standard 35 of this report. 31/03/06 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 OP7 OP7 Good Practice Recommendations The registered manager should look at how the detail of planned activities could be improved in all service users weekly activities plans The registered manager should improve service users plans to include more details about individual abilities, as described in Standard 7 of this report, in order to maintain service users independence The registered manager should keep service users monthly care plan review records separate for each service user as described in Standard 7 of this report The registered manager should include in the homes Adult Protection policy, simple guidance for staff in how to respond to and report adult protection issues The registered provider should introduce a better system for recording repairs and maintenance as described in Standard 19 of this report The registered provider should ensure that all staff preemployment checklists are completed as an aid to monitoring that best practice is being adhered to regarding recruitment. 3 4 5 6 OP7 OP18 OP19 OP29 Welcome Care Home Ltd DS0000025650.V281740.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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