Inspection on 13/11/07 for Westholme Clinic

This inspection was carried out on 13th November 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

Westholme Clinic 08/12/08

Westholme Clinic 02/11/06

Westholme Clinic 30/06/05

Westholme Clinic 27/09/04

Westholme Clinic 10/05/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOMES FOR OLDER PEOPLE Westholme Clinic Clive Avenue Goring-By-Sea Worthing West Sussex BN12 4SG Lead Inspector Mrs D Peel Unannounced Inspection 09:45 13 November 2007 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 Westholme Clinic DS0000024239.V347213.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. Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westholme Clinic Address Clive Avenue Goring-By-Sea Worthing West Sussex BN12 4SG 01903 242423 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) carol@ashbournegrp.freeserve.co.uk Westholme Clinic Limited Mrs Patricia Ann Cummins Care Home 55 Category(ies) of Dementia (55), Dementia - over 65 years of age registration, with number (55), Mental disorder, excluding learning of places disability or dementia (55), Mental Disorder, excluding learning disability or dementia - over 65 years of age (55) Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 55 services users may be accommodated. Date of last inspection 2nd November 2006 Brief Description of the Service: Westholme Clinic is a Care Home providing nursing and is registered to accommodate up to 55 people in the category of DE(E) (persons over 65 years with dementia), DE (dementia), MD(E), (mental disorder over 65 years), MD (mental disorder). It is a detached property located in Goring-by-Sea, in the town of Worthing. The accommodation for service users is arranged over two floors. The ground floor and first floor are served by a passenger lift. The bedrooms comprise predominantly of single occupancy, although there are three shared rooms. Westholme Clinic Limited privately owns the service and the responsible individual on behalf of the company is Mrs Shoai. The registered manager responsible for the day-to-day management of the home is Mrs Patricia Cummins. Fees range between £400 and £600 per week. Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Diane Peel carried out this unannounced visit to Westholme Clinic on the 13th November 2007. During this visit the intended outcomes for 31 standards were assessed; these included the key standards for care homes providing a service to older people. Prior to the visit to the home previous inspection reports and information gathered about the home since it was last visited in November 2006 were reviewed. Have Your Say surveys were returned to CSCI by eight relatives, one member of staff and two healthcare professionals prior to the visit. This information was used to inform the inspection process. The Annual Quality Assurance Assessment (AQAA) was returned to The Commission for Social Care Inspection (CSCI) prior to this visit to the home. During the course of the visit the inspector met many of residents and spoke with those who were able to converse with the inspector in either in the privacy of their bedrooms or in the communal areas. A case tracking exercise for four people living at the home was undertaken to look at how the assessed needs of this group of residents with diverse needs were being met. Staff were spoken with during the visit and observed during their interaction with people living at the home. What the service does well: A professional returning a have Your Say survey to CSC said “ the care service always strives to provide the best physical and psychiatric care to clients. Also they are supportive to relatives who may find residential care a difficult option.” A member of staff returning a survey commented that “ the ongoing training is very good and I have learnt a lot.” Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 6 The standard of food is good with choices of alternatives available. From observing staff and people living at the home the inspector was able to conclude that staff encourage people to retain their individuality, they were kind and encouraging in their approach. Care plans are comprehensive and have clear guidance of how people care is to be delivered. What has improved since the last inspection? What they could do better: A relative returning a survey to CSCI said “ continued attention to detail needs improvement such as cleaning spectacles, making sure shoes on feet, making sure fixadent applied to false teeth and spectacles are put on.” Another relative suggested that the care home could improve by offering the “ opportunity to travel out from the home (mini bus etc.)” Further bathrooms and toilet facilities need to be refurbished and modernised. Records in the home must be kept in accordance with Regulation 17 of the Care Homes Regulations. Photographs of all people living in the home must be kept and the visitor’s book must be used effectively to record people visiting the home. Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 7 Environmental risk assessments must address the practice of holding bedroom doors open without self-releasing devises and the fire officer must be consulted about this practice. 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. Westholme Clinic DS0000024239.V347213.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 Westholme Clinic DS0000024239.V347213.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): 1,3,4,5,6 People who use the service experience good outcomes in this area. People, who come to live at the home and their families, have information available to make an informed choice about where they want to live and people’s needs are assessed before they move to the home, so that they know that the home can meet those needs. EVIDENCE: Westholme Clinic has a Statement of Purpose and Service Users guide which was provided on the day of the visit to the home. Seven out of the eight relatives returning Have Your Say surveys to CSCI said that they had enough information about the home to help them make a decision whilst the other person didn’t answer the question because they didn’t understand it. Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 10 The homes own quality assurance surveys were observed to ask peoples satisfaction with the information provided prior to admission and communication during admission to the home. For most people this process was scored well. Out of the nine surveys returned to the home only one scored low. Information provided in the AQAA reports that all service users are assessed prior to them moving into the home by a qualified nurse and that discussions with social workers, families, friends and if possible the person themselves take place. All prospective people who may come to live at the home are invited to visit the home and stay for a while. The AQAA states that “ all service users come on a trial period of one month.” And “we offer a respite care if a bed is available.” The care records for four people living at the home were viewed during the visit and their needs case tracked. Dates of pre assessments were recorded and for two people the actual pre admission assessment forms were observed in their records. The staff working at the home are well trained and information in the AQAA reports that the majority of staff have an NVQ level 2 or 3 with five staff having achieved the ASET level 2 certificate in Dementia Care and two members of staff have certificates in palliative care. Intermediate is not offered at Westholme Clinic. Westholme Clinic DS0000024239.V347213.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): 7,8,9,10 People who use the service experience good outcomes in this area. Care planning systems give clear information to assist with all aspects of health, personal and social care needs so that the changing needs of people living at the home can be monitored EVIDENCE: The care records for four people were viewed during this visit to Westholme Clinic to see how the assessed needs had been used to form a plan of care which staff could follow to make sure that people living at the home are having their needs met. All four peoples care records set out a plan of care, which would inform both nursing staff and care staff on how people need should be met. A condensed version of the care plans was observed to be present in each person’s bedroom for quick access to staff. Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 12 Care plans viewed had been reviewed regularly and showed the changing needs of individuals of individuals and where appropriate demonstrated the involvement of peoples relatives or representatives in making decisions. An example of this was for one person who was at risk from falls. Consultation with their next of kin had reached an agreement of what could be put in place to limit falls lessen risks to that person. Records of visits and interventions by other health care professions were observed to be kept in care records seen and demonstrated ongoing monitoring of health care needs. All eight relatives Have Your Say surveys to CSCI report that their relatives needs were “always met.” Two health care professionals returned Have Your Say surveys to the home. Both responded to the question “ Are individuals health care needs met by the care service?” with “always.” and one healthcare professional commented, “ the care service always strives to provide the best physical and psychiatric care to clients” and the other said, “I have always found on my visits to Westholme Clinic that the staff respect their residents and care for them in a sensitive and organised manner. The senior staff make it their business to check on individual needs and problems.” Medication was observed to be kept in a metal locked trolley in a lockable room. Additional medication was observed to be being kept in locked wall cupboards. The nurse in charge on the day of the visit confirmed that only qualified nurse administer medication and sample initials for those nurses were observed to be in place at the front of the administration of medication record book. Medication records seen were in good order with no gaps in recording. The nurse in charge said that the home had controlled drugs prescribed for some people living at the home and provided the controlled drugs record book. Controlled medication was sampled and found to be accounted for. During the visit people were observed to be treated with respect and how people were to be addressed was recorded in their plan of care. One relative returning a survey to CSCI commented “ they offer support and dignity to people who cannot care for themselves.” The two health care professionals returning surveys to CSCI both reported that they felt that the service respects individual’s privacy and dignity. Westholme Clinic DS0000024239.V347213.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): 12,13,14,15 People who use the service experience good outcomes in this area. People living at the home are encouraged to maintain contact with their family and friends. The home is friendly and staff respect the privacy and dignity of residents and the activity programme is flexible to cater for individual residents abilities so that they experience variation to daily living. EVIDENCE: Peoples social and recreational needs are recorded in their care plans and it was observed that information had been gathered about peoples past history from relatives or friends. There was some evidence of craft activities, which people have taken part in on display in the main dining room above the fish tank and there were photographs on display. On the afternoon of the visit a few people joined a career in a gentle exercise session in the dining room. Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 14 A health professional returning a survey to CSCI said, “ This home provides a package of care tailored to meet clients and carers needs.” A relative returning a survey to CSCI commented, “ They always encourage people in their care and allow complete freedom of movement within the home “ and the cared for person is encouraged to join in activities that are on offer. The home has an open visiting policy and on the day of the visit visitors were observed to be made welcome by staff and provided with refreshments. The home has a visitor’s book, which records most visitors to the home, but it was observed that not all visitors arriving during CSCI’s presence in the home signed the book. Information about advocacy service were observed to be on display on the notice board and there was evidence of such service membership in some peoples care records. The AQAA returned to CSCI reports that when a person moves into the home they write to their relatives with details of the advocacy service. The menu for the main meal of the day was on display in the dining room and showed that the meal was savoury mince, potatoes and brussel sprouts followed by a lemon sponge pudding with a lemon and lime sauce. The inspector joined people living at the home at lunch time and chose an alternative of a cheese sandwich but did have the sponge pudding for desert which was very light and tasty. The AQAA returned to CSCI reports that alternative menu is if people do not like the main meal of the day and this was confirmed by staff spoken with. People able to eat without assistance were given the time and opportunity to retain their independence whilst for other people there was assistance from staff. It was observed however that none of the staff sat down with the people who they were assisting. When asked in the survey to relatives from CSCI “what do you feel the care home does well? one relative reported “fresh cooked real food.” The kitchen staff confirmed that they continue to cater for two other care homes owned by the same organisation. Westholme Clinic DS0000024239.V347213.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): 16,18 People who use the service experience good outcomes in this area. The complaints procedure enables those using the service to have the confidence that any complaints will be taken seriously and responded to. Arrangements are in place to protect people using the service from being place of harm or abuse. EVIDENCE: The complaints procedure is included in the Service User Guide and on display on the notice board opposite the office door. Complaints records were viewed during the visit to the home and observed to be detailed and outcomes to complaints recorded. The AQAA returned to CSCI reported that there had been five complaints made in the last 12 months of which all five had been investigated within 28 days and this corresponded with the complaints records seen during the visit. Four out of the five complaints had been upheld. Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 16 Seven out of the eight people returning Have Your Say surveys to CSCI reported that they knew how to make a complaint and one person didn’t respond to the question. Westholme Clinic has a safeguarding adults policy, which the AQAA returned to CSCI prior to the visits records, was last updated in July 2006. The AQAA reports that there have been two safe guarding referrals investigated by the appropriate local authorities through the safeguarding adults procedures. Training records showed that there is ongoing training for staff in safeguarding adult’s procedures and a member of staff spoken with reported that the safeguarding training is regularly updated. Westholme Clinic DS0000024239.V347213.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): 19,20,21,22,23,24,25,26 People who use the service experience adequate outcomes in this area. Ongoing redecoration and refurbishment is improving the environment so that people have a more comfortable and homely environment to live in. EVIDENCE: The main communal areas of the home are reasonably well maintained. There are four lounges, a dining room and a conservatory with smaller sitting areas around the home. Since the last visit to the home, work has begun on the modernisation of the bathrooms and toilets. One bathroom has been completely upgraded and has an overhead hoist. The wall tiles, floor tiles and toilet and hand washing Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 18 facilities have been replaced in some other facilities. On the day of the visit the handyman was continuing this work in another toilet. Most bedrooms at the home are for single use. Some people had taken the opportunity to personalise their rooms with the assistance of their families but for others rooms looked basic. The maintenance man spoken with during the visit confirmed that as rooms become vacant they are redecorated and spoke about the continued work that they were carrying out on the bathrooms and toilets. It was observed during the visit that some beds have been replaced with modern electric nursing beds. For the majority of relatives returning the homes own quality assurance surveys were satisfied with the accommodation. One person returning a survey to CSCI commented, “some bathrooms and toilets are in need of cleaning and redecoration. Westholme Clinic DS0000024239.V347213.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): 27,28,29,30 People who use the service experience good outcomes in this area. People living at Westholme Clinic are protected by the recruitment procedures and staff receive appropriate training and supervision so that they can meet the needs of people living at the home. EVIDENCE: Discussion with the nurse in charge during the visit confirmed the staffing levels for that day as being: three qualified nurses and six care staff in the morning, and nine staff in the afternoon until the night staff come on duty which included qualified nurses. The rota observed confirmed staffing levels. Another member of the care team spoken with confirmed that a qualified nurse is on duty at night to support the night care team. Information provided in the AQAA returned to CSCI reports that “ the majority of care staff have an NVQ level 2 or 3. Five members of staff have achieved Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 20 the ASET Level 2 certificate in Dementia care. Two members of staff have certificates in Palliative Care.” One member of staff spoken with commented, “ the organisation is very good with the training.” The records of three staff were observed during this visit to the home, which included one person recently employed. They were observed to include evidence of Criminal Record Bureau (CRB) and Protection of Adults (POVA) checks. A job application was on file, two written references, photograph, proof of the person’s identity and completed equal opportunity monitoring forms and health declaration forms. Training certificates were present in these files and letters confirming places on particular training courses. There was also a list of training events on display in the office identifying those people who were to attend. A member of staff returning a Have Your Say survey to CSCI said “ I was given a very good interview by the matron, all check were done professionally.” About their induction they said, “The matron covered everything that I needed to know and the on going training is very good.” Three relatives returning Have Your say surveys to CSCI made comments about the staff: “I have never seen people work so hard to care for people in need as I have at Westholme.” “ this home provides care in which the relatives can have confidence.” Another relative said “ more staff so that they can have time to take residents out into garden.” Westholme Clinic DS0000024239.V347213.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): 31,33,35,37,38 People who use the service experience adequate outcomes in this area. People living at the home and their relatives can be confident that the manager wants to run the home in the best interests of the people that live there, but to achieve this must continue to improve the home and ensure that people have a home where all risks to their safety have been identified and action taken to minimise these risks. EVIDENCE: Mrs Cummings is the registered manager at Westholme Clinic. She has the NVQ level 4 Registered Managers Award, the ASET Level 2 in Dementia Care and a certificate for Palliative Care. Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 22 There are ongoing improvements to the home, which Mrs Cummings has identified in the AQAA returned to CSCI prior to the visit to the home. A quality assurance system is in place, which consults with relatives of people who live at the home, solicitors, and professionals who visit the home. Recently returned surveys were viewed at this visit to the home. The AQQ reports that the registered provider visits the home regularly and writes reports about their findings. These were not requested by CSCI on the day of the visit. The administrator spoken with during the visit to Westholme confirmed that it is still the policy of the home not to manage the financial affairs of people who live at the home. Any expenditure not included in the fees are invoiced directly to peoples representatives. Three out of the four sets of care records viewed did not contain a photograph of the person and the nurse in charge confirmed that no other records had photographs of people living at the home on them. For some people living at the home communication problems mean that they are unable to confirm their identity if they were to go missing or for reasons such as new staff been unfamiliar with them or medication being administered to the correct person and so a statutory requirement has been that the home has a photograph of each resident. Risk assessments are carried out but there was no risk assessment for rooms where people were being cared for in their rooms and doors were being wedged open. The nurse in charge explained that this was because they were more at risk with the door closed. There were other unoccupied rooms being held open with chairs and for one room a coat hanger held the door open attached to a cupboard door. Whilst looking around the home it was observed that at least one commode surround and one toilet aid in place in a bathroom were rusty. The nurse in charge explained that commodes had been replaced recently so the one seen during the visit must have got missed and this was removed during the course of the visit. Westholme Clinic DS0000024239.V347213.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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 2 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Westholme Clinic DS0000024239.V347213.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 OP19 OP21 2 OP37 17.1 Regulation 23.2 (b) Requirement The registered person must continue to improve the bathroom facilities within the home. Records specified in schedule 3 must be kept at the home. This includes a photograph of each resident. Environmental risk assessments must address the practice of holding bedroom doors open. Advise form the fire officer must be sought with regard to keeping doors open. Timescale for action 01/04/08 01/01/08 4 OP38 13.4 (a) (c) 01/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Westholme Clinic DS0000024239.V347213.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Westholme Clinic DS0000024239.V347213.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. 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