Inspection on 21/05/07 for Willan House

This inspection was carried out on 21st May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Willan House 23/06/08

Willan House 09/01/07

Willan House 03/10/06

Willan House 18/08/05

Willan House 18/04/05

Willan House 08/11/04

Willan House 23/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Willan House Willan House Stainfield Market Rasen Lincolnshire LN8 5JL Lead Inspector Elisabeth Pinder Key Unannounced Inspection 09:30 21st May 2007 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 Willan House DS0000059327.V334407.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. Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willan House Address Willan House Stainfield Market Rasen Lincolnshire LN8 5JL 01526 398785 01526 399719 willan.house@btconnect.com 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) Mr John Shiers Mrs Christine Shiers Mr John Shiers Care Home 20 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10) of places Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mr and Mrs Shiers are registered to provide personal care at Willan House for service users of both sexes whose primary needs fall within the following categories:Old age, not falling within any other category (OP) 20 Dementia DE(E) 10 The category DE(E) applies to service users aged 60 years and over The maximum number of service users to be accommodated at Willan House is 20 9th January 2007 2. 3. Date of last inspection Brief Description of the Service: Willan House cares for older people in a non-smoking environment in a detached property situated in the small village of Stainfield. The home is approximately four miles from the small town of Wragby and ten miles from the historic city of Lincoln. The home stands in its own grounds and gardens with car parking facilities to the front. The home has two floors and a stair lift is fitted to both staircases to the bedrooms on the first floor. There are a variety of aids and adaptations around the building allowing service users to move round the home more independently. Sixteen of the bedrooms are single, six of them have en-suite toilet facilities. There are five communal toilets, two communal bathrooms and a disabled shower room. The home has a web site giving detailed information about the services offered. The current weekly fee range is £335.00 - £425.00. Additional costs are made for hairdressing, chiropody and newspapers. These are all private arrangements and costs are met by individual service users. Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken by two inspectors and formed part of a key inspection. The visit lasted six and a half hours and took into account previous information held by The Commission for Social Care Inspection (CSCI) including previous inspection reports, their service history, and records of any incidents that had been notified to the CSCI since the last inspection. Prior to the visit three residents ‘Have your say about’ questionnaires were received and comments from these will be mentioned throughout this report. Information has also been taken from the homes pre-inspection questionnaire and this has been used to plan the visit. The site visit focussed on all the key standards and consisted of case tracking a sample of four people’s records, talking to them, observing staff interaction and assessing their care. A general conversation was held with some people whilst they were sitting in the lounge and a period of observation was undertaken during lunch. One member of staff, two visitors and both providers were spoken with. An improvement plan had been requested after the last inspection identifying the action that is being taken to meet outstanding requirements. This document will be mentioned throughout this report. What the service does well: What has improved since the last inspection? Twenty-two requirements were made during the previous visit and an improvement plan was requested from the providers. This details the action Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 6 being taken to address requirements and the majority of these now meet current legislation. The home’s statement of purpose and service user guide now includes details of the complaints procedure, however, as stated below a timescale should be included. More detailed information has been written in pre-admission assessments, however, these must cross reference with care plans. All care plans are being re-written and those examined have significantly improved and show that residents or their relatives/representatives have been consulted. A gender policy has been written and residents are now offered choice regarding who provides personal care. The medication policy was reviewed in March 2007 and a homely remedies policy was seen together with letters showing agreement by two GP’s (General Practitioner). The providers have downloaded a copy of Lincolnshire County Councils revised safeguarding adults protocol and are amending the home’s procedure to ensure it follows local guidelines. Records are now being kept of the temperature in the home at night. Staff supervision has re-commenced and records showed that the majority of staff now have regular meetings to discuss any care issues, their performance and training needs. A deputy manager post is being created to assist with the management of the home. The manager is currently having support and supervision from an outside supervisor and has completed a one-day workshop covering appraisals and leadership skills. What they could do better: Care plans must continue to improve, these should be concise and person centred to ensure all staff know what they must do to ensure the needs of residents will be met. Information obtained prior to admission must always be used to develop the plan of care. All records must be signed and dated by persons completing them. All staff must have training to ensure they have a good understanding of how to treat people with dementia care needs. The complaints procedure must state a timescale by which people are informed if any action is to be taken to address their complaint. To ensure safe administration of medicines, medication must not be signed for before it is given to residents. Staffing rotas should show when the providers are in the home and in what capacity, for example, working a specific shift, cooking or office work. Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willan House DS0000059327.V334407.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 Willan House DS0000059327.V334407.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): 2 & 3 Standard 6 is not applicable Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People coming into this service have access to a range of information to help them make a decision about moving into the home and they are involved in an assessment of their needs prior to being admitted. EVIDENCE: The service user guide and statement of purpose both contain sufficient detail about the home to help people understand the services that are offered. The guide details what people can expect and gives clear information about the fees payable and any additional costs. The requirement to include full details of the complaints procedure has been addressed, however, this should also include a timescale by which people are informed if any action is to be taken. All resident questionnaires identified that people had received enough information about the home before they moved in so they could decide if it Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 10 was the right place for them and all identified that they had been issued with contracts. One resident told us that they had initially come to stay for a weekend but when they went home they wanted to go back as they had felt safe in the home. They stayed for another seven days before making a decision to stay permanently and ‘loves it’. Peoples’ comments in the statement of purpose include ‘mum’s health and will to live have improved 100 ’ and ‘staff are excellent and patient’. The improvement plan details the action taken to address the requirement regarding more detailed information being written in pre-admission assessments. Those written for two new residents were examined, and both gave much more information, however, not all cross reference with care plans. Willan House DS0000059327.V334407.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are not person centred and concise therefore, peoples’ needs may not be met. Staff respect the wishes and preferences of people living in this home while maintaining their privacy and dignity EVIDENCE: The providers have taken action to address the requirement made regarding a lack of detail in care plans. Four care plans were examined and these have significantly improved and show that residents or their relatives/representatives have been consulted. However, evaluations of the plans vary in frequency. Files contain quite a lot of repetition and multiple assessments which have not always been used to write the plan of care. For example, information in a moving and handling and bathing assessment for one resident identified that they cannot lift their arms above 90° but no reference is made in their care plan, another referred to ‘Parkinson’s’ and ‘Glaucoma’, but again there was no mention in this persons care plan. Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 12 Some risk assessments have been written and others are being developed to identify potential risks to residents. These include falls, manual-handling assessments and medication. Those that are in the process of being written should show an overall conclusion as to whether the risk has been assessed as low, medium or high. Each file has a ‘life story book’ but these have not yet been completed. Daily records written by staff were clear and records show that people have access to health care professionals. Whilst we acknowledge that care records are all being re-written a lot had no date or signatures. A discussion was held with the providers and it was agreed that all records should be signed and dated by the person completing the record. Since the last inspection a gender policy has been written and residents are now offered choice regarding who provides personal care. A key worker system is used but those responsible for the people whose care was tracked were not on duty. One member of staff was interviewed and she did not have a good understanding of how to care for people with dementia or communication difficulties. Two ‘have your say about’ questionnaires identified that residents ‘always’ receive the care and support they need and one identified ‘usually’. All identified that they ‘always’ receive the medical support needed. People spoken with in a general conversation said they felt their privacy and dignity are always respected and staff members were observed carrying out their duties with kindness and sensitivity. The improvement plan details the action taken to address the requirements regarding medication and information taken from the pre-inspection questionnaire identified that the medication policy was last reviewed in March 2007. The homely remedies policy was seen together with letters showing agreement by two GP’s (General Practitioner). Staff were observed giving medication to residents at lunch time and the staff member involved said she had completed training by the home’s pharmacist and receives regular updates from the providers. She had a good understanding of the correct procedures to follow, however, medication was signed for before it was given to residents. This was discussed with the providers who said that they had identified this in the monthly audits and this is being addressed. Willan House DS0000059327.V334407.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are able to enjoy a lifestyle which is flexible and they are able to make choices about food and activities. EVIDENCE: Information in the home’s pre-inspection questionnaire lists the activities available and these include a range of activities aimed to meet the needs of people living in this home. However, resident questionnaires received varied as to whether activities are arranged that they can take part in, two identified ‘usually’ and one ‘sometimes’. Specific comments written read ‘activities are available but I usually prefer to stay in my room’ and ‘subject to gradual decrease of personal mobility’. One resident said that he is very happy and is able to spend the time as he wants to. He also said he went to Skegness with some other people last week and enjoys going out with his son. During the visit some residents were helping to put plants in tubs for the garden, these were brought into the lounge and residents were observed choosing plants and putting them into the pots. Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 14 Records showed that regular church services are held in the home and residents are able to attend religious meetings of their choice outside of the home. Residents confirmed that visitors are always welcomed and one visitor said ‘this is a really homely place’. Another relative praised the care given to her mother by both staff and the providers. Of the three resident questionnaires received, two identified that they ‘always’ like the meals at the home and one ‘usually’. People spoken with during the visit were very complimentary about the food, one resident said ‘it’s too good, I’ve gained a stone’, another said ‘the food is good, plenty of it and offered choice’. A group of six residents chatted generally about the food and all gave positive comments, no one identified any areas needing improvement. Observation during the lunchtime period saw residents chatting with each other and staff were on hand to help residents when required. The main meal was meat pie, mashed potatoes and fresh vegetables and everyone said it was ‘lovely’. Willan House DS0000059327.V334407.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in this home are confident that any concerns would be addressed appropriately and there are now satisfactory procedures in place for reporting allegations of adult abuse, but not all staff have received training in this subject. EVIDENCE: The home has a complaints procedure, which tells people how to make a complaint and how it will be handled. However, as previously stated this does not include a timescale by which people are informed if any action is to be taken. A copy is given to all new residents in the Service User Guide and one was available in the entrance to the home. No complaints have been made since the previous visit. Three people who returned surveys identified that they all know how to make a complaint. Not all residents spoken with could remember seeing the complaints procedure but all said that they would feel confident speaking to their relatives or staff if they had any concerns. Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 16 The previous inspection was carried out as part of a safeguarding adults investigation, this has now concluded and action being taken to address the issues raised is detailed in the providers’ improvement plan. The providers have downloaded a copy of Lincolnshire County Councils revised safeguarding adults protocol and are amending the home’s procedure to ensure it follows local guidelines. One member of staff spoken with had a satisfactory knowledge of the types of abuse that could occur but was unclear of the action to take should she need to report any allegations. Training records given to us showed that this member of staff had not done any training in safeguarding adults and the provider said she is due to attend the next course. Willan House DS0000059327.V334407.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 & 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 this home live in a clean, pleasant and hygienic environment and they are able to personalise their rooms. EVIDENCE: The bedrooms of four people were seen and these were comfortable, clean and furnished with their own personal items. Residents commented that their rooms are always kept very clean. During the previous inspection the radiator in one of the bedrooms was not working and the providers said that they had had great difficulty in finding a plumber. However, during the visit a plumber came to assess the problem. Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 18 All ‘have your say about’ questionnaires identified that the home is ‘always’ fresh and clean and during the visit the home was clean and tidy and no unpleasant odours were noted. The Environmental Health Officer visited the home in January and has awarded a three star certificate. Specific comments on his report read ‘more attention to cleaning needed’ and the manager said that the kitchen is being refurbished this week. A recommendation was given during the previous inspection that records should be made of temperature in the home at night. Records are now being kept and showed that the lowest temperature was recorded to be 20 degrees at 03:00 hrs. Willan House DS0000059327.V334407.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers are in sufficient quantity for them to be able to care for people living in this home. Staff training has been given priority to help staff develop a better understanding of what they must do to meet the needs of residents. EVIDENCE: Two weeks staffing rotas were examined and these showed that there are usually three staff on duty between the hours of 08:00 and 17.30hrs and two staff between 18:00 and 08:00. Neither of the providers are recording their hours on the rota, unless the manager is due to cover specific shifts and after a discussion about this they agreed to record these to show when they are in the home and in what capacity. Staff spoken with said they felt that there are enough staff on duty to meet the needs of the residents currently living in the home, they always have time to complete their tasks without rushing and have time to sit and talk to residents. Two residents questionnaires identified that staff are ‘usually’ available when needed and one ‘always’. All identified that residents feel staff listen and act on what they say. Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 20 Residents spoken with said that ‘staff are lovely, they seem to use a lot of agency staff, but the agency staff are nice’ and ‘it’s friendly here, you can say what you like and have a bit of fun’. During the visit staff were observed to treat people with respect and were available to attend to needs. Information in the pre-inspection questionnaire showed that 53 of care staff have achieved the National Vocational Qualification (NVQ), which is a recognised training award in care. Training undertaken within the last twelve months included Dementia Care, level 2, dementia awareness, safe handling of medicines, fire evacuation and fire awareness, medicines and the elderly, adult protection and safe moving of adults. A discussion was held during the previous inspection regarding training for staff regarding equality and diversity, to date this has not taken place. However, the providers have displayed a poster on the dignity challenge, looking at both good and poor practice. Since the previous visit two new staff members have been employed and their records showed that they had been recruited using robust procedures based on equal opportunities. Satisfactory CRB/Pova checks had been received prior to their employment and staff have been given copies of the General Social Care Council (GSCC) code of conduct. New staff are provided with an induction book covering areas such as understanding of care principles. Staff supervision has re-commenced and records showed that the majority of staff now have regular meetings to discuss any care issues, their performance and training needs. Minutes of staff meetings were seen where staff receive information and can air their views. Willan House DS0000059327.V334407.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, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service is being well managed with procedures in place to ensure the health and safety needs of residents are met and the quality of care provided is monitored. EVIDENCE: The home is run by Mr & Mrs Shiers, who are the registered providers. Mr Shiers is also the registered manager and has completed the Registered Managers award. Two requirements were made during the last inspection and as part of the safeguarding adults investigation. Both are currently being addressed and we Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 22 were informed that a deputy manager post is being re-advertised as recent interviews did not find a suitable person and the manager is having support and supervision from an outside supervisor every two months. He has also completed a one-day workshop covering appraisals and leadership skills. Pre inspection information shows that a range of policies and procedures are available and these include, quality assurance, control of substances hazardous to health, equal opportunities, fire safety, food safety and nutrition and health and safety. All were dated being reviewed in January 2007. Staff said that they have access to policies and procedures as they are kept in the office. Records show that fire equipment checks, fire evacuation drills and fire safety training are carried out regularly. Accident records are in place and since the last inspection records showed that none of these needed to be reported to the Commission. Residents’ files are stored securely in a locked office. The providers do not deal with residents financial matters, these are looked after by families or representatives. The providers said that their annual development plan is currently being typed up and this will be sent to us on completion. Their quality audit system includes sending questionnaires to residents, their families or representatives and new residents. Willan House DS0000059327.V334407.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 3 3 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 Requirement Care plans must be concise and person centred to ensure all staff know how to care for each individual person. Information gathered prior to admission should always be used in the care plan. Timescale of 31/01/07 not met, however, it is acknowledged that care plans are being re-written. To ensure safe administration of medicines, no medication must be signed for before it is given to residents. The complaints procedure should give a timescale by which people are informed if any action is to be taken. All staff must be adequately trained to ensure they have the skills and knowledge to carry out their roles. Timescale of 28/02/07 not met, however, it is acknowledged that the majority of staff have undertaken training. Timescale for action 30/06/07 2. OP9 13[2] 30/06/07 3. OP16 22[4] 30/06/07 4. OP30 18[1]c 31/07/07 Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 25 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 OP30 OP36 Good Practice Recommendations All staff should receive training to ensure they have a clear understanding of equality and diversity. Formal supervision should take place for all care staff at least six times per year. Willan House DS0000059327.V334407.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lincolnshire Area Office Unity House, The Point Weaver Road Lincoln LN6 3QN 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 Willan House DS0000059327.V334407.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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