Care Home: St Theresa`s Rest Home

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What the care home does well Residents benefit from a caring and supportive staff team who provide a good level of care in a homely and friendly environment. Residents were very positive regarding the care and support they receive at the home. A number of residents described the staff as "very kind". Residents were also positive about the manager of the home. Staff have good opportunities to attend training and the manager is clearly committed to ensuring the staff team are appropriately trained. The staff at the home know the residents well and ensure that their needs are met. The residents commented favourably about the food provided by the home. Prospective residents have good assessments carried out of their needs before they move into the home and care plans indicate that their physical, social and health needs are addressed. Visitors are encouraged and welcomed. What has improved since the last inspection? Ten requirements were issued at the last inspection. The registered manager has complied with all of these. The temperatures of wash hand basins are maintained within safe limits. Three requirements have been complied with in relation to the health and safety of the kitchen area and a recent environmental health visit found no major issues of concern. The fire alarm is tested weekly and night staff have regular fire drills to protect residents. Window restrictors have been fitted to windows in residents` rooms. Care plans are being reviewed on a regular basis so that possible changes in people`s needs are being updated. The results of quality monitoring questionnaires are being published so that residents know how well the home is doing in meeting its aims and objectives. Resident`s photographs are now attached to their individual medication charts to further ensure the safe administration of medication at the home. What the care home could do better: Four new requirements and three new good practice recommendations have been issued as a result of this inspection. Although no residents currently have pressure sores or nutritional problems it is prudent to carry out such assessments on all residents at the home on a regular basis. Staff should be reminded to ask residents what time they would like to retire of an evening to maximise choice at the home. Some radiators may present a risk to residents and so need to be covered. When references are received by the home they should have a company stamp or letter headed paper enclosed to confirm their authenticity. A staff training overview should be developed so the manager knows when staff need refresher course in mandatory training such as moving and handling. The systems for holding and handling residents` money needs to be more robust and records need to be clear so that residents` money can be easily accounted for. CARE HOMES FOR OLDER PEOPLE St Theresa`s Rest Home 6-8 Queen Anns Garden Enfield Middlesex EN1 2JN Lead Inspector Mr David Hastings Key Unannounced Inspection 09:30 8th November 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 St Theresa`s Rest Home DS0000045869.V341862.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. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Theresa`s Rest Home Address 6-8 Queen Anns Garden Enfield Middlesex EN1 2JN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8360 6272 F/P 020 8360 6272 Mrs Lila Cecilia Paul Mr Jose Roy Paul Mrs Lila Cecilia Paul Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home will not admit service users with a diagnosis of dementia, however, four named service users with dementia can be accommodated as long as the home can meet their needs. The home must advise CSCI when any of these named service users no longer reside at the home 15th June 2006 Date of last inspection Brief Description of the Service: St Theresas is a privately run home owned by Mr Jose Paul & Mrs Lila Paul and registered to accommodate twenty-three older service users of either sex. The home is a large converted house in a tree-lined road in Enfield. The bedrooms are on three floors and are comprised of thirteen single bedrooms and five double bedrooms. One single room and one double have en-suite facilities. The lounge/dining area is on the ground floor with a conservatory attached. There is a large garden to the rear of the house. The home is well serviced by public transport and there are shops nearby. The stated aim of the home is to foster an atmosphere of care and support which both enables and encourages our residents to live as full, interesting and independent a lifestyle as possible with rules and regulations kept to a minimum. The current scale of charges range from £406 to £465 per week. A copy of this report is available on the CSCI website and / or from the home. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 8th November 2007 and lasted six hours. We were assisted throughout the inspection by the registered manager who was both open and helpful. We spoke with four staff on duty during the inspection. We spoke with eight residents of the home and observed the interactions between staff and residents. We also spoke with three visitors to the home. We inspected the building and examined various care records as well as a number of policies and procedures. The residents we spoke with said they were satisfied with the care and support they received. One resident told us, “I’m very grateful for all they have done for me”. What the service does well: What has improved since the last inspection? Ten requirements were issued at the last inspection. The registered manager has complied with all of these. The temperatures of wash hand basins are maintained within safe limits. Three requirements have been complied with in relation to the health and safety of the kitchen area and a recent environmental health visit found no major issues of concern. The fire alarm is tested weekly and night staff have regular fire drills to protect residents. Window restrictors have been fitted to windows in residents’ rooms. Care plans are being reviewed on a regular basis so that possible changes in people’s needs are being updated. The results of quality monitoring questionnaires are being published so that residents know how well the home is doing in meeting its aims and objectives. Resident’s photographs are now attached to their individual medication charts to further ensure the safe administration of medication at the home. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 6 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. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (6 not applicable) People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Good information is available to prospective users of the service about the home. Assessments are completed before people move in to make sure that their individual needs can be met. EVIDENCE: We looked at the “Service User Guide”. This gives people information about the home and services and facilities available. The information was very detailed and included a statement about how the home encourages people from different backgrounds to use this service. Two assessments were examined of people who had recently moved into the home. These assessments were detailed and covered all the elements required by this standard including the assessment of physical, emotional, social and cultural needs. We also found that the information from these assessments was being recorded on peoples’ care plans as well. There was evidence that people St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 9 moving into the home have a review of their placement after four to six weeks to see if they are happy at the home and whether they decide to move in on a permanent basis. All the residents we spoke with said they were happy with the care they received. One person told us the staff were, “Very good”. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff at the home know the residents very well and how best to support them. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Six people’s care plans were examined. These contained information regarding all aspects of care outlined in Standard 3 and were sufficiently detailed to enable staff to understand the individual needs of person. There was evidence that these plans were being reviewed monthly and any changes in people’s needs were being recorded on their plans. Plans also contained a section for residents to comment on the care they receive at the home. There was evidence from care plans that people have good access to health care professionals such as doctors, chiropodists, district nurses and opticians. People who use the service confirmed that they had good access to health care St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 11 professionals. Appropriate risk assessments were in place relating to moving and handling and other risks associated with dementia. A requirement has been given that all residents in the home have risk assessments in place to highlight any possible issues with pressure care or nutrition. This has not impacted on residents as no one at the home currently has any pressure sores or problems with eating, however it is prudent to carry out such assessments. Satisfactory records were examined in relation to the receipt, administration and disposal of medication at the home. Records indicated that staff have undertaken medication training and only qualified staff administer medication at the home. No one at the home currently manages their own medication. A requirement, issued at the last inspection that a photograph of each resident is placed on the front of his or her MAR chart has now been complied with. We saw a number of examples of good staff interactions with people and staff were able to give practical examples of how they ensure the privacy of people they support. We saw staff knocking on resident’s bedroom doors before entering. People we spoke with told us that the staff were respectful towards them. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 12 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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides activities for people who use the service in order to keep them suitably occupied and engaged. The home encourages visitors, which ensures an interesting and lively atmosphere. Residents are able to exercise choice and control over their lives. The home provides people with a wholesome appealing balanced diet. EVIDENCE: Residents’ likes and dislikes regarding activities are being recorded on their individual care plans. Staff provide activities for residents they support. During the inspection staff were observed playing games, dancing and sitting and chatting with residents, which made for a friendly and relaxed atmosphere. It was clear that the residents and staff were enjoying each other’s company. One resident told us, “I usually help out about the home”. Other residents confirmed that staff went out shopping with them on occasions. A number of residents have developed dementia whilst at St Theresa’s and the manager is currently looking at ways to ensure these residents are kept suitably occupied and engaged. The manager has recently attended a training course on this issue. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 13 Visitors to the home told us that they felt welcomed by staff when they visited. Residents told us that they could have visitors at any time. The home has an open visiting policy and the record of visitors that was examined indicated that there were regular visitors to the home throughout the day and evening. One visitor to the home told us, “I can ask them about anything”. On the day of the inspection a number of friends and family were visiting people at the home. Staff we interviewed were able to give us practical examples of how they offer choice to people living at the home. One resident told us, “ I have a mind of my own, if I didn’t like it here I would leave ”. People we spoke with confirmed that they had choice and control over their lives. The manager said that the staff always ask people if they want to go to bed and some people stay up late. Some people said that they sometimes did not feel they had a choice about when they went to bed of an evening. A good practice recommendation has been issued that staff are reminded to ask residents when they would like to go to bed and that this is reflected in residents’ daily notes. The kitchen was clean, fridge and freezer temperatures were being recorded and there were sufficient amounts of fresh fruit and vegetables available. The cook was interviewed and had a good knowledge of individual resident’s dietary needs and preferences. The bin in the kitchen had been replaced and now had a lid fitted. People who use the service confirmed that the food was good at the home and that they always get enough to eat. The lunch on the day of the inspection was pork casserole or meat pie. Lunch was relaxed and sociable and residents were being offered choice in terms of dessert. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 14 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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. People at the home are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has introduced a “Comments, suggestions and complaints” book, which details minor concerns from residents and their relatives as well as the action taken by the manager. People we spoke to said they had no complaints about the service. One complaint has been recorded in the last twelve months and records seen indicated that this was dealt with appropriately and according to the policies and procedures in place. The home has a policy and procedure in relation to safeguarding adults from abuse. Staff we interviewed were able to give us examples of how people could be at risk from abuse and their responsibilities in relation to reporting any suspicions of abuse at the home. The manager has attended a “train the trainers” course in safeguarding adults and has trained all staff in adult protection in house. People who use the service told us that they felt safe at the home. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 15 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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The owners are working hard to improve the general condition of the premises and the home is clean, comfortable and has a homely atmosphere. EVIDENCE: The outside of the home has recently been painted and looked very nice. The registered provider has made substantial improvements to the home both inside and out and the general condition of the home has improved. Written confirmation was seen that the wash hand basins can be safely maintained close to 43 degrees without affecting the hot water supply to the kitchen. This was a requirement that was restated at the last inspection that has now been complied with. Some work surfaces in the kitchen have been replaced and the freezer is working properly. These were two other requirements that have now also been complied with. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 16 During a tour of the premises we noticed that a number of radiators were not covered. A number of residents in the home are confused and may inadvertently use the radiator for support. One radiator in the toilet could present a risk if someone fell against it. A requirement has been issued that risk assessments are carried out on all radiators in the home and all radiators are covered that may present a risk to residents. Staff at the home have undertaken infection control training and certificates were seen on files examined. The laundry area was clean and the washing machine has a sluice cycle for heavily soiled laundry. All toilets had paper hand towels and anti-bacterial soap available. On the day of the inspection all parts of the home were clean and free from offensive odours throughout. People who use the service told us that the home was always clean. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 17 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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are supported by a committed and caring staff team who have a good understanding of their individual needs. Staff receive the training they need to carry out their duties and responsibilities effectively. Residents are protected by the home’s thorough recruitment procedures. EVIDENCE: People who use the service were very positive about the staff at the home. One person commented that, “They work very, very hard”. There appeared to be sufficient staff on duty to meet the needs of the residents on the day of the inspection. Staff interviewed had an excellent understanding of the needs of the residents and interactions observed between staff and residents were supportive, friendly and caring. Staff rotas were available for inspection and found to be satisfactory. The rota indicated that there are three care staff on duty throughout the day and at night there are two waking night staff. The manager stated that currently 76 of staff have achieved NVQ level 2 or equivalent. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 18 Training records that were examined indicated that staff have undertaken appropriate training and staff interviewed were able to give examples of recent training they had attended and how the training had informed their work practices. Staff were positive about the training opportunities available to them at the home. Records seen indicated that some senior staff members now require refresher courses in moving and handling. A requirement has been issued relating to this in the relevant section of this report. It may be useful for the manager to develop a staff training overview in order to highlight any need for refresher courses as well as to highlight any general training needs of staff. A good practice recommendation has been issued. Two staff files were examined. All these files contained the information required by this standard including CRB disclosures, proof of identity and two references. A good practice recommendation has been issued that referees are requested to provide a company stamp or enclose letter headed paper to further evidence the authenticity of references. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager of the home knows the residents very well and understands their needs. Residents have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded but better systems need to be adopted to record this. The health and safety of residents and staff are promoted and protected. EVIDENCE: The registered manager, Mrs Paul, has completed the registered managers award and there was evidence that the manager attends training on a regular basis. Staff, visitors and residents were positive about the manager of the home. One person told us the manager was, “Easy to talk to”. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 20 The manager of the home undertakes regular quality monitoring reviews. These take the form of questionnaires and meetings with residents and their families generally on a one to one basis. The results of the quality assurance questionnaires are now published and made available to residents and other stakeholders. This was a requirement from the previous inspection that has now been complied with. The home holds small amounts of money on behalf of residents. This money is used to purchase small items and to pay for hairdressing. A random selection of this money was inspected. Although the manager and staff were able to account for the money it was not being maintained to a satisfactory standard. Some money had been given to either staff or family members to buy items for the resident but this had not been recorded on the record of accounts. Resident’s individual accounts were not up to date. A requirement has been made that the procedures and policies for handling and holding money on behalf of residents are reviewed in order to ensure more robust systems for recording and accounting of residents’ money. Satisfactory records were examined in relation to fire safety. The fire alarm is tested weekly and night staff undertake fire drills every three months. These were requirements from the last inspection that have now been complied with. Window restrictors are fitted to all windows in residents’ rooms. This was also a requirement from the last inspection. Satisfactory certificates were seen in relation to electrical installation and PAT testing, gas safety, fire safety and lift maintenance. An environmental health visit had been undertaken on 26/10/07 and no major issues had been identified. St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 12(1) b Requirement Timescale for action 01/01/08 2. OP19 13(4) a The registered person must ensure that all residents at the home are assessed for the risk of developing pressure sores and undertake a nutritional assessment on a regular basis. The registered person must 01/01/08 ensure that risk assessments are carried out on all radiators in the home and all radiators are covered that may present a risk to residents. The registered person must ensure that all staff including senior staff undertake refresher courses in mandatory training including manual handling. The registered person must ensure that the procedures and policies for handling and holding money on behalf of residents are reviewed in order to ensure more robust systems for recording and accounting of residents’ money. 01/01/08 3. OP30 18(1) c 4. OP35 16(2) l 01/01/08 St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations The registered person should ensure that residents are asked when they would like to retire to bed of an evening and any changes to the residents’ routine are recorded in their daily notes. The registered person should ensure that all references received by the home include a company stamp or letter headed paper to confirm authenticity. The registered person should ensure that a staff training overview is developed so that it is clear when staff require a refresher course in mandatory training. 2. 3. OP29 OP30 St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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 St Theresa`s Rest Home DS0000045869.V341862.R01.S.doc Version 5.2 Page 25 - 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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