Inspection on 25/09/07 for West House

This inspection was carried out on 25th September 2007.

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.

Other inspections for this house

West House 08/12/09

West House 30/06/09

West House 22/09/08

West House 03/10/06

West House 06/03/06

West House 06/10/05

West House 30/03/05

West House 23/11/04

West House 31/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE West House 11 St Vincents Road Westcliff On Sea Essex SS0 7PP Lead Inspector Helen Laker Unannounced Inspection 25th September 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address West House DS0000015565.V346842.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. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West House Address 11 St Vincents Road Westcliff On Sea Essex SS0 7PP 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) 01702 339883 01702 346518 www.westhousenursinghome.co.uk Rootcroft Limited Barry Gelfand Mrs Helen Chitiga Care Home 25 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (25) of places West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1.The registered person may provide the following categories of service only - Care home with nursing - Code N - to service users of the following gender: Either Whose primary needs on admission are within the following categories: Old age, not falling within any other category - Code OP Dementia Code - DE 2. The maximum number of service users who can be accomodated is 25. 2. Date of last inspection 3rd October 2007 Brief Description of the Service: West house is an established care home that is registered for twenty-five older people. Of the twenty-five beds available, fifteen currently are used for people with dementia and up to six are being used as transitional beds via an acquired contract with Southend Hospital PCT. West House also caters for residents requiring nursing care. Although the home predominantly accommodates residents of the Jewish faith, this is not exclusively the case and residents of other faiths (or no faith) are also accommodated. The home consists of a traditional residential property, which has been modified and extended to meet the needs of older people. The shaft lift and stair lift gives access to all three floors where accommodation and communal areas are situated. The home has thirteen single and six double bedrooms, many of which include en-suite facilities. The access to one of the bedrooms is via sloped flooring; there are adequate handrails around the corridor areas where these bedrooms are located, one bedroom is accessed via a small number of steps and one has a useable fire exit. The patio area is accessed from the conservatory and is laid out with tables and chairs; it overlooks a grassed area of the garden. The garden is accessible via a ramp and has a further seating area; it is nicely laid out with shrubs and flowers in the summer. The home is situated close to local shops and amenities and is within easy reach of the main shopping area; the seafront and local theatre are also nearby. There is a limited amount of parking to the front of the home. At the time of this report, six beds were contracted by the Primary Care Team for transitional service users prior to permanent placement in residential or West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 5 nursing care homes or community based home care. The home was first registered in July 2002. The Service User Guide and Statement of Purpose have been reviewed in line with the acquired transitional hospital contract and residents and their representatives can be provided with this information. The home has available to review current Commission for Social Care Inspection reports too. At the time of this report the director supplied a scale of the homes charges and fees these range from £379.47 to £750.75 per week. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection which took place over one day with one inspector in the home. This unannounced inspection, was undertaken on the 25th September 2007 with the assistance of the director. There was a tour of the grounds and an inspection of records and documentation. Time was spent discussing the care of the service users. Further feedback was also received from service users and staff through completed surveys, telephone contact and discussion. Survey responses have been included in the relevant sections of the report. A pre-inspection questionnaire and other reports and correspondence provided by the home were also used as evidence to inform this report. The director and nurse in charge of the day to day management of the home and staff were spoken with. Twenty three National Minimum Standards were inspected on this occasion, twenty overall outcomes were met and there were four requirements and two recommendations detailed in the full report. Discussion of the inspection findings took place with the director and nurse in charge of the day to day management of the home at the end and throughout the inspection and pertinent guidance was given. The Home’s email address is Westhouse-Nursing-Home@whnh.co.uk. This information will automatically be included within the Service Information section of this report. What the service does well: What has improved since the last inspection? The Proprietor has updated the statement of purpose and service users guide in line with current service user provision, and they are available for reference. The admission procedure has improved highlights some shortfalls but overall includes an adequate assessment, which ensures that service users needs overall can be met. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 7 Consideration has been given to consultations and service user choice when using crash mats and the stairgate, and bedrails and documentation put in place. The home is working to ensure that 50 of care staff undertakes NVQ training at a minimum of level 2 in care. Mandatory training updates are being addressed for all staff and reviewed regularly. The requirements at this inspection have decreased it should be noted that all key standards were inspected on this occasion and this is a comprehensive report which details all areas which require actions to be taken. 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. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a Statement of Purpose and Service User’s Guide which can be made available. Present and prospective service users and their supporters are given adequate information about the home so that they can make informed choices. The admission procedure overall includes an adequate assessment, which ensures that service users needs can be met. A definition as to whether the home provides transitional/respite care still needs to be clear and some documentation put in place. EVIDENCE: The statement of Purpose and Service User Guide have been updated in June 2007 and now meet all the requirements of Regulation 4. Documents are updated regularly in line with current service user provision, and are available for reference. The inspector was told that all service users are given copies but this still could not be confirmed by service users and relatives spoken to. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 10 A pre-admission assessment is generally carried out by the manager and is recorded. Pre admission assessments were reviewed for the homes most recent admissions and were found to be adequately completed. Wherever possible it is advised that residents or their relatives are involved in the assessment process. Residents individual contracts were not reviewed at this inspection. The inspector was informed previously that prospective service users are invited to visit the home pre-admission, but some are unable to do so. In addition, staff generally visit service users before admission. Residents spoken with confirmed their relatives visited the home prior to making a decision regarding admission. Six transitional/respite service users are now provided for via a contract started 1st September 2006 and dedicated space is integral with the whole home. Service provision and evaluation of staff competence regarding short stay is being developed. Service user feedback and consultation with the placement officers and discharge coordinator are being arranged to support development of the service. Stepdown service provision is reviewed on a daily basis and weekly with the social worker and discharge co ordinator, external physio and OT. The admissions and discharge policy is to be updated in line with step down procedures. A definition as to whether the home provides transitional/respite care still needs to be clear and documentation updated, as in some cases the above may not be required. This has been discussed with the proprietor. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Each service user has an individual plan and service users are supported to take risks as part of an independent lifestyle via a process of assessment. While obvious improvement has been made to the care planning process some further progress is required to ensure that service users needs are met. The health needs of service users are well met although better documentation would ensure clarity of needs. Medication administration and recording was noted to require minor improvements but has improved since the last inspection. Personal support is provided in a way that promotes dignity. EVIDENCE: Evidence of three service user care plans indicated that their basic health, personal and social care needs are recorded within an individual plan of care. Instructions for staff to meet service users’ care needs were not on all occasions clear and comprehensive. Care plans did not always evidence service users’ or relatives’ involvement and those seen were reviewed on a regular West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 12 basis. Daily recording although improved since the last inspection requires more improvement to ensure they detail the welfare of the service user, how they spend their day and the progress of the care plan. Risk assessments again although improved were available for most service users but were also noted to require more detail in some areas and include potential complications of the risk. The director was advised of current issues during the inspection. There was evidence to show that the home ensures that residents are supported to access all the community health facilities. The inspector was informed that only trained staff administer medication. Completed drug histories should still refer to dose changes on the form. All individual entries on the drug sheets should be signed by the transcriber and checked for accuracy with a countersignature. The dose form and strength and time of medication was not clearly recorded on all treatment charts. Shortfalls were noted with the maintainance of records in respect of the medicines received into the home and administered to people who live there. Creams prescribed for another resident with the label ripped off were found in another residents room. The home must adhere to the procedures for the receipt, recording, storage, handling, administration and disposal of medicines. Residents and relatives spoken with expressed their satisfaction with the care they received and felt that staff always respect their privacy. Observations throughout the day indicated that staff treat residents in a caring and unhurried manner. All shared rooms had adequate screening to ensure residents privacy and dignity whilst personal care is being carried out. The manager stated at the previous inspection that most residents open their own mail, those that are not able to usually have their relatives’ assistance. The director said that should a resident require staff to assist them, the mail would be opened in the presence of the resident and read to them; residents spoken with confirmed this. The home has a cordless phone that is used by residents for making personal calls; one resident has their own personal phone in their bedroom. The home provides a visitors room to enable residents to see their visitors in privacy, if they do not wish to use their bedroom. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A wider range of meaningful pastimes needs to be developed to promote the residents mental and physical wellbeing. Links with families are good and contacts are maintained. Choice in the routine of the day can and should be adapted to ensure residents rights are maintained. The home provided good food in ample quantities and is served in a congenial setting. EVIDENCE: The home does not have a set activities programme but do have a diary and a weekly activities list. The home does not have a designated activities co ordinator. Residents have stated that they play cards, bingo, listen to music, and reminiscence sessions and have singalongs; they also told of the regular weekly visits by the musicians that they said was most enjoyable. The director spoke previously about the visits to local pubs and the seafront that had occurred in the preceding months. Two residents previously spoken with stated that a mini-bus would allow them to go out more and the proprietor stated that some do not wish to go out and choices are respected. Information about resident’s choices and preferences for activities of living are not consistently West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 14 recorded for the people living at the home. It is accepted that a number of people living at the home may not wish to or be capable of participating in activities. However records in respect of meaningful occupational and stimulating activities must still be consistently recorded. More could still be done in respect of the social and leisure activities provided by the home. Relatives spoken with said that they can visit when they wish and are always made welcome and can always speak to the manager. Residents described the food provided by the home as very nice. The home employs a chef who is prepared to cook any meal to accommodate individual residents needs. Residents spoken with said the food at the home is excellent and that they get three courses, however the evening meal is too early. The dining area is spacious and clean and overlooks the garden; some residents preferred to eat their meal in the lounge area. The food was well presented in served in sufficient quantities. Visitors spoken with commented on the quality and the quantity of the food served. Carers prepare the evening tea and the proprietor is reminded that this should not detract from care duties. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy which informs complainants of their rights. Staff do receive relevant training relating to the protection of vulnerable adults. EVIDENCE: The home has a detailed complaints policy and procedure and people may raise concerns formally or discuss any issues in a more informal way with the homes manager and director. It was reported by the director that there has been one complaints made since the previous inspection. Informal and verbal complaints are now logged in a manner which records the outcomes. The home has an Adult Abuse Policy and Whistle Blowing procedure. Most staff have attended “Protection of Vulnerable Adults” training. The last POVA training was held on 21st September 2007 and is included in the homes common induction standards. The home must continue to ensure that all staff receive training and updates in the protection of vulnerable adults and ensure through the home’s supervision procedures that all staff are fully aware of what is expected of them. West House DS0000015565.V346842.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. West House was generally bright and well maintained and provided the service users with safe, homely and comfortable surroundings. Not all staff were totally aware of the fundamental concepts of restraint. EVIDENCE: West House is an adapted large house, which provides accommodation for residents on three floors, accessed by a passenger lift, and a staff lift. The premises are generally well maintained with an attractive garden to the rear. Furniture and furnishings are to a good standard. There is CCTV coverage to the front entrance. The proprietor previously informed that maintenance is carried out as and when required basis. The furniture and furnishings around the home are of a good standard. Communal facilities include a large lounge diner and conservatory. Many of the bedrooms are en-suite and there are sufficient adapted toilets and West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 17 bathrooms. At the last inspection the home had recently added two single ensuite bathrooms. The accommodation in terms of bedroom space meets the standards for homes registered before August 2002 Bedrooms were found to be well furnished and personalised to individual tastes, and some will require re-decoration in the near future. The proprietor informed that carpets have been replaced and the lounge redecorated. The home was found to be generally clean and tidy throughout with some isolated odours. West House DS0000015565.V346842.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Adequate staffing levels are currently maintained to meet the needs of service users. Recruitment practices currently are poor and have major shortfalls which need addressing. Staff training is addressed but more prominence should be paid to appropriate updates being undertaken to provide a competent work force. EVIDENCE: Staff rotas indicated that agreed staffing levels of 1 nurse, 5 carers on the early shift and 1 nurse plus 4 care during the afternoon and evening. Numbers have not changed and staff on duty during the inspection matched those stated on the duty rota. There are nine qualified nurses employed at the home and one is on duty at all times. The home employs eighteen care assistants, two have completed their NVQ level two and another two are currently working towards it. One has NVQ level three and another two are studying for it. Of the staff records reviewed it was noted that improvements had been made and records were more ordered with only some minor shortfalls were evident. Some documentation was noted to not be signed or dated or even in place in some cases. The process regarding agency and volunteer recruitment should the need arise, and CRB checks was discussed. Attention should be paid when recruiting to permissions to work and proof of identity. The director was also West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 19 previously advised of current immigration requirements and regulations and the recruitment checks required. He was advised to inspect other staff personnel records to ensure that the home was compliant with all legal requirements and seek clarification from relevant bodies. All new staff undertake the common induction standards training It was noted at the homes last inspection the director has recently developed a staff handbook that will be given to all existing staff in addition to new staff. All mandatory training is carried out as part of the induction; specialist training is identified according to the resident needs. Staff previously spoken with said that the training provided by the home is good. A plan is in place and updates are being addressed. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 25 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is guidance and direction to staff and the home does overall have in place practices that will promote and safeguard the health, safety and welfare of the people using the service. Regular fire drills must be undertaken and maintained. EVIDENCE: The home does not currently have a registered manager. The proprietor is currently applying for registration and has achieved the registered manageres award. Staff and residents spoken with previously and as part of this inspection felt he was easily approachable and supportive. There are clear lines of accountability and residents and / or their relatives can meet with the West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 21 manager and are consulted and kept up to date with changes to the day to day running of the home. The proprietor is in the home most days and times, in a supernumerary capacity and oversees the day-to-day running and provision of care and treatment. Residents and their relatives can discuss care and any issues with him informally or formally when they visit. The home’s policies and procedures and records have all been reviewed between April and June 2007. Competent and skilled nursing staff support the manager. Care staff are supervised and supported on a regular basis in the work enviroment. There was no evidence to suggest the home is not financially viable. The home holds cash for residents; records of transactions and the balance of the cash were examined were found to be correct. Regular charges previously for hairdressing were without a receipt, it was advised that a receipt should be obtained and stored with each individual’s transaction records. The new accident book was noted to be in use at the homes last inspection, all accidents were accurately recorded in it. Safety certificates were inspected and were all up to date, regular checks are made on fire equipment. The director said that fire drills are carried out regularly, however the last fire drill documented was on 22nd January 2007. Fire drills at a minimum of one quarterly were discussed and must be documented appropriately. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) 17(1)(a)( b) Requirement A detailed service user plan of care must be drawn up including consultation with service user families and significant multidisciplinary personnel, to be reflected in the care plan and be completed sufficiently and reviewed comprehensively monthly. (This is a repeat requirement. Previous timescale of 30th November 2006 not met) Timescale for action 21/12/07 2. OP9 13(2) The registered person shall make 21/12/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Where MAR charts are handwritten by staff these records should be checked, countersigned, correctly completed and regularly reviewed so as to minimise the risk of errors and omissions. Please also note that where residents receive liquid or topical applications the dose and frequency should be recorded as part of the care and treatment DS0000015565.V346842.R01.S.doc Version 5.2 Page 24 West House plan and kept under regular review. (This is a repeat requirement. Previous timescale of 1st April 2006 and 30th November 2006 not met) 3. OP12 16 (2) m &n 21/12/07 The routines of daily living and activities made available must be flexible and varied to suit service user’s expectations preferences and capacities. This with reference to the formulation of a formal activities plan in appropriate formats, with regard to differing service users needs. (This is a repeat requirement. Previous timescale of 30th November 2006 not met) The registered person must operate a robust and thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. (Previous timescales of 1st April 2006 and 30th November 2006 not met.) 21/12/07 4 OP29 7, 9, 19 (1) to (7)Schedu le 2 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 OP31 OP38 Good Practice Recommendations The home should have a registered manager and it is noted an application is in progress. The home should review its fire risk assessment and ensure that regular fire drills are carried out and the outcome recorded. West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 West House DS0000015565.V346842.R01.S.doc Version 5.2 Page 26 - 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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