Inspection on 10/06/08 for Wells Court

This inspection was carried out on 10th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Wells Court 29/10/07

Wells Court 21/03/07

Wells Court 13/03/06

Wells Court 26/07/05

Wells Court 02/02/05

Wells Court 15/09/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Wells Court Herbert Road Salcombe Devon TQ8 8HD Lead Inspector Graham Thomas Unannounced Inspection 09:00 10 and 16th June 2008 th 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 Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wells Court Address Herbert Road Salcombe Devon TQ8 8HD 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) 01548 843484 01548 843484 courtgroup@btinternet.com Wells Court Limited Manager post vacant Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24), Old age, not falling within any other category (24), Physical disability over 65 years of age (24) Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age 55/65 Date of last inspection 29th October 2007 Brief Description of the Service: Wells Court is a detached property situated in the estuary town of Salcombe in the South Hams area of South Devon. It is registered to provide care for 24 older persons who may also have a physical disability and/or dementia. Accommodation is provided in single bedrooms on three floors. A passenger lift and chair lifts provide access to the upper floors. Most bedrooms have en-suite facilities. There is a spacious lounge, a smaller lounge and a dining room situated on the ground floor. At the front of the building there is a small garden and patio area. Car parking is provided at the rear of the building. Appropriate aids and adaptations are available to assist people. Written information regarding the home and the services provided is available in the reception area and is given to people considering going to live at Wells Court. A copy of the most recent CSCI inspection report was also available in the reception. The current level of weekly fees range from £350 to £450. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 star. This means the people who use the service experience adequate quality outcomes. We used various methods to complete this inspection. Before the inspection we looked at information sent to us by the Provider telling us about their service. This is called an Annual Quality Assurance Assessment. We also looked at surveys returned to us by people using the service and their relatives. We examined our own records of notices sent us about incidents in the home and about complaints. We visited the home on two separate days and spoke with people living in the home, staff, visitors and visiting professionals. While we were there we examined people’s care plans, staff records and other records about the running of the home. What the service does well: What has improved since the last inspection? • • • • • • • Individual care plans are clearer and contain the information staff need to provide good care. People who administer their own medicines are assessed to check if there is a risk to them in doing this The physical and health care provided by staff has improved There is a better system in place to deal with maintenance issues around the home There is a clear staff training plan to help staff provide the care and support people need The change of staffing has been welcomed by people living in the home and has been accompanied by improvements in the service. The new manager is popular with staff and people who live in the home DS0000003852.V363137.R01.S.doc Version 5.2 Page 6 Wells Court 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. The summary of this inspection report can be made available in other formats on request. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 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 Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving to Wells Court can feel confident that the home will make sure it can meet their needs before providing them with care and support. EVIDENCE: People with whom we spoke during our visit felt that had received enough information about the home before moving in. They found staff helpful and supportive during this process. One person who completed a survey told us, “I was assessed before coming into the home. Therefore I was told about the home and family came and looked around and they were made to feel very welcome” Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 9 A hospital staff member with responsibility for arranging placements for people on leaving hospital wrote to us. She had to arrange a placement for a patient and told us, “…I discovered that her .. (spouse).. was already a Wells Court resident…I rang the home and was delighted by their open and helpful response. They communicated information between their resident and myself very promptly and made extra efforts to ensure the best outcome for both their resident and my patient.” The home’s “Statement of Purpose” and “Service User Guide” provide written information regarding the home and services it provides. It is given to people considering moving to the home and was also available in the reception area. Since the last inspection these have been modified to provide more accurate information about the management and staffing structure of the home and organisation. Four care plan files were examined. These contained assessments made before the person’s admission to the home or soon after. The home’s assessment procedure gave people moving in the opportunity to provide written feedback about their admission. Some of the details in the assessments had not been fully completed. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements made since our last inspection mean that people living in the home receive a better standard of care. However, people remain at risk due to poor recording practice concerning medication. EVIDENCE: People with whom we spoke during our visit said that they were satisfied with the care they received. Two people talked about how the service had improved. One person told us, “ I’m very happy. They spoil me rotten!” In the surveys returned to us by people living in the home, people stated, “I am well looked after, very comfortable, well fed” and “All staff very attentive and caring” Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 11 One relative told us that everyone was “..very helpful and hard working and act on any request” We looked at four individual care plan files. A new care planning format had been introduced to make the plans more user-friendly. The plans provided details of each person’s health and personal care needs as well as useful information about their individual history, personal routines and preferences. There were risk assessments for each person about their environment and specific issues such as self-medication. There were also agreements as to how much each person wanted to be involved in their plan. Some forms were not fully completed but the plans generally gave a clear picture of each person’s needs. The plans showed details of how individual health care needs were being met. These included, for example, pressure area assessments. There were records of appointments and visits by Doctors, the Community Nurse and Chiropodist. While we were at the home, the Community Nurse Manager visited, whom we interviewed. She told us that she had noticed improvements in the way that the home were addressing people’s health needs. A new senior carer had proved particularly keen to learn from her and ensure that the home was complying with the treatments prescribed for individuals. People with whom we spoke felt that they were treated with respect and that their dignity was preserved. In a survey returned to us one person stated that they found the staff “easy to talk to and very helpful”. During our visit staff were observed knocking on doors before entering and addressing people respectfully. People living in the home and staff talked with each other with ease and good humour. We examined at the home’s system for administering medicines. These were stored in a secure medicines trolley and cupboard with a key pad entrance lock. Since the last key inspection on 29th October 2007 a new refrigerator had been purchased for the storage of medicines that require cool storage. Two people had been admitted to the home who administered their own medicines. Risk assessments had been produced in both cases in accordance with a previous requirement. At last our key inspection we found that the use of medicines was not recorded accurately and made a requirement about this. We made a random inspection visit on 4th March 2007 and found that this requirement had not been met. In this Key inspection visit we found that one person’s record was arranged so that the dates on which the medicines were signed for were wrong. We also found medicines that had been administered and not signed for in three records. Some doses of medicine had been signed for in advance. One person was said to have refused a dose of medicine but this was not recorded. The numbers of tablets remaining for one person did not agree with the records in two instances. Failure to keep an accurate record of medicines places people at Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 12 risk of not receiving the correct medication when they need it. There is also a risk that medicines may be lost or stolen. An immediate requirement notice was issued concerning this matter. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 and 16 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Wells Court are generally well supported to pursue a lifestyle which suits their individual preferences. EVIDENCE: Since our last visit, care plans had improved and showed individual preferences, interests and routines. People with whom we spoke confirmed that they were able to follow their own routines in the day. One person, for example preferred spending time in her room completing puzzles and doing tapestry. Others were spending time in the home’s lounges. A list of activities for the week was displayed in the foyer. This included, for example, bingo, local paper review, music and movement and an “open house cream tea”. In surveys returned to us by people living in the home, most said that there were “usually” activities in which they could take part. Some people with whom we spoke during our visit said that they would like more activities and more one-to-one time with staff. People confirmed that religious services were held regularly in the home and some stated that they attended church with friends or relatives. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 14 During our visit, various people visited the home including family members. Those with whom we spoke all confirmed that they were made welcome by the staff. People living in the home confirmed that they were able to receive visitors in private if they wished and that staff were welcoming and helpful. People told us that they “always” or “usually” liked the food in the home. The cook told us that a daily choice was available and there were records of what each person had eaten. On most days, people had taken the main choice on offer. Some people with whom we spoke did not appear aware there was a choice, though one told us that staff would always provide an alternative if they did not like what was on offer. We looked at the menus, which showed a varied diet. At the time of our visit nobody in the home required a special diet. However discussion with the cook about previous residents demonstrated that he was able to cater for particular requirements. The home’s dining room was light and airy and pleasantly laid out. People confirmed that they could take meals here or in their own rooms. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Wells Court and their relatives can feel confident that staff will listen to their concerns and act upon them. Although procedures are in place to protect people from abuse, staff are not sufficiently aware of these procedures. EVIDENCE: Since our last inspection of the home, we have received one anonymous complaint. The issues were examined during our visit. It was found that there was either no evidence to substantiate the complaint or that practice had improved since the complaint was made. The home has a written complaints procedure and this is included in information provided to people moving into the home and their relatives. Two relatives who returned surveys and one with whom we spoke stated that they had no reason to complain but felt confident that any complaint would be treated seriously. All the people living in the home who returned surveys stated that they knew how to make a complaint. People told us that staff listened to their concerns and felt that this had improved. Comments we received included, “The staff are very caring and helpful, always ready to listen”. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 16 We examined staff files and found that staff had received training in safeguarding vulnerable adults from abuse. In discussion with staff, all were able to say how they would report abuse within the organisation. However, they were not clear as to how they might report abuse to other external agencies if required, though this information did appear in the home’s policies and procedures. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Wells Court are provided with a generally clean, safe and well maintained environment. EVIDENCE: Wells Court is situated in a quiet residential area on the outskirts of Salcombe. Accommodation is provided in single bedrooms on three floors. A passenger lift and chair lifts provide access to the upper floors. Most bedrooms have en-suite facilities. There is a spacious lounge, a smaller lounge and a dining room situated on the ground floor. At the front of the building there is a small garden and patio area. Car parking is provided at the rear of the building. The home is decorated and furnished in a homely style and people’s own rooms were decorated, furnished and equipped to suit their individual tastes Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 18 and requirements. There was evidence of upgrading and refurbishment such as the fitting of new carpets and hot water regulator valves to hand basins. Some maintenance defects were found during our visit and these were attended to immediately. A maintenance log was seen which recorded repairs carried out by the organisation’s maintenance team. Security bolts fitted to two bedroom doors which were lockable from the outside were disabled / removed during our visit. Our observations, examination of care plans and discussion with a visiting Community Nurse Manager confirmed that people had the aids and adaptations they required such as pressure relieving mattresses. On inspection the home was found to be generally clean and free from unpleasant odours. People who responded to our surveys said that this was “always” or “usually” the case. At our Key inspection in October 2007 a requirement was made to repair the laundry floor to eliminate a trip hazard. This was repeated at our random inspection in March 2008. During our most recent visit we noted that the floor covering had been taped down as a temporary solution. However, the floor in this area is in a generally poor condition with areas of exposed concrete. This needs to be made impermeable to reduce this risk of infection. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service received by people living in the home has improved with changes of staffing. However, further improvements in recruitment practice are needed to maximise the protection of people living there. EVIDENCE: Since our last key inspection visit, all but one of the staff have been replaced by new staff or staff from other parts of the Court Group. People living in the home, professionals and relatives have all told us that this has been accompanied by improvements in the service. One person living in the home commented that “The staff are now more helpful and they listen to what you say” The staffing rotas showed a regular care staffing pattern of 4 in the morning, 3 in the afternoon. This included the manager and/or deputy manager. One member of staff remains awake at night and another sleeps on the premises. In addition, there is a cook who is on duty for the preparation of lunch and tea except at weekends when care staff prepare the meals. This pattern was confirmed in discussion with staff. On one day per week a contact cleaner attends to clean the home. On other days this is cleaning currently carried out by care staff. The manager stated Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 20 that adverts were being placed for a cleaner to work on three mornings per week. Feedback from relatives suggested that they felt there could be more staff. In our conversations with people living in the home, some stated that they would like more one-to-one time with staff and said that activities such as bingo were sometimes curtailed because of staff shortages. Recruitment practices had improved notably since the last key inspection. We examined three staff files and discussed recruitment with these staff. The files contained more information and showed that references were taken up prior to employment. Where verbal references had been taken, these were recorded. It was noted that one member of staff previously employed in another company within the Court Group was still awaiting the outcome of a criminal records check. There was no record of the person who was responsible for the person’s supervision during the period until the new check had been completed. It was also noted that criminal some recent records checks were being made for “The Court Group” rather than Wells Court Ltd. Such certificates are not valid as The Court Group is not the staff member’s employer. These details are important so that people living in the home are provided with the maximum possible legal protection. Staff training issues were discussed with the manager and training records were examined. Some evidence was seen that the nationally recognised “Skills for Care” staff induction programme was being prepared for implementation though this had yet to be put in place at the time of our visit. Most staff who had not completed a National Vocational Qualification in care were either undertaking a course or about to start one. This training was supplemented by the organisation’s own in-house training in subjects such as food hygiene and moving and handling. Evidence of these short courses was contained in staff files and confirmed in discussion with staff. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home has improved since our last key inspection. However, further improvements are needed in quality monitoring and staff supervision to ensure the safety and wellbeing people living in the home. EVIDENCE: In October the Registered Manager left Wells Court. Since that time temporary management arrangements have been in place. A manager has been appointed who has been mentored by an experienced consultant. During our visit the manager showed us her completed application which was awaiting a criminal records check so that it could be submitted to the Commission. This check arrived during our visit. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 22 A quality assurance system has been put in place which involves canvassing the views of people living in the home and others. Before this inspection an Annual Quality Assurance Assessment was completed and returned to us. This identified the improvements made and showed clear plans to address previous shortfalls. However, it is evident form this visit that ongoing quality monitoring requires more “fine tuning” to address recurring issues such as repeated shortfalls in medication recording which are fundamental to the wellbeing of people living in the home. The amount of monies held for people living in the home is limited. Individuals or their representative manage their financial affairs. Records were kept of incoming and outgoing payments of any money held in safekeeping for people living in the home. We inspected a sample of three records and found that they did not agree with the amounts of money held in two instances. In one instance the money held was £5 less that the record indicated. In the other instance it was a small amount in excess of the record. It is important that such records are accurate to protect the financial interest of people living in the home. Records of staff supervision were examined. These showed that staff had not received regular recent supervision. This is important to ensure that staff can give and receive feedback about their practice and the welfare of people living in the home. Staff training records showed that they were receiving training in subjects related to health and safety such as moving and handling, fire safety and food hygiene. We also examined various documents which demonstrated that essential servicing and maintenance were being carried out to ensure the safety of staff and people living in the home. These included, for example, a record of recent bath hoist servicing, and maintenance of the gas system and a current contract for the removal of contaminated waste. The door to one bedroom fire door was found to catching on a newly fitted carpet and not closing. This posed a potential risk to the occupant of the room during a fire. An immediate requirement notice was issued concerning this matter. Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 2 x 2 Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The medicines administration records must reflect accurately the medicines actually administered (or not). Each medicine must be signed for as it is administered. Timescales 29/2/08 and 18/3/08 not met. Immediate Requirement Notice issued. The Registered Person must render the laundry floor impermeable to reduce the risk of infection. The Registered Person must ensure there is a clear record of the arrangements for the supervision of any new staff member who commences duty prior to the receipt of a satisfactory criminal records check. The Registered Person must ensure that criminal records certificates are sought using the name of the employer rather than “The Court Group” for all employees. The Registered Person must ensure that there is accurate DS0000003852.V363137.R01.S.doc Timescale for action 16/06/08 2. OP26 13(3) 16/08/08 3. OP29 19(11) 16/07/08 4. OP29 19(1)(b) 16/07/09 5. OP35 13(6) 16/07/08 Wells Court Version 5.2 Page 25 6. OP38 23(4)(a) recording of all monies held on behalf of people living in the home The fire door to room 8 must be eased so that it closes automatically 17/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations People should have more opportunities for stimulation available through leisure activities, which are linked to their needs, interests and capacities. The registered person should ensure that staff are aware of the external agencies to whom safeguarding issues might be referred and under what circumstances this might be done. The management should risk assess people’s safety in gaining access to and using the garden and review the security arrangements when people enter and leave the premises. The registered person should ensure that the quality assurance system is sufficiently rigorous to identify and eliminate repeated poor practice. The registered person should ensure that all staff receive regular supervision. 2. OP18 3. OP19 4. 5. OP33 OP36 Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wells Court DS0000003852.V363137.R01.S.doc Version 5.2 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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