Inspection on 22/09/05 for Abbeymere Care Centre

This inspection was carried out on 22nd September 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Abbeymere Care Centre 11/03/09

Abbeymere Care Centre 21/02/08

Abbeymere Care Centre 21/08/07

Abbeymere Care Centre 20/03/07

Abbeymere Care Centre 04/01/06

Abbeymere Care Centre 24/03/05

Abbeymere Care Centre 18/05/04

Abbeymere Care Centre 08/07/03

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Strad House 12 Eggington Road Stourbridge West Midlands DY8 2QJ Lead Inspector Mr Jon Potts Unannounced Inspection 22nd September 2005 9:45am 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 Strad House DS0000024951.V253243.R01.S.doc Version 5.0 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. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Strad House Address 12 Eggington Road Stourbridge West Midlands DY8 2QJ 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) 01384 395195 01384 395195 Karelink Limited Mrs Judith Christine Boden Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (12), Physical disability over 65 years of age (6) of places Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24/3/05 Brief Description of the Service: Strad House is registered for the categories of 12 older people and 6 people with physical disabilities over the age of 65. The Home aims to offer residents the opportunity to enhance their quality of life by providing a safe, manageable and comfortable environment, plus support and stimulation to help them maximise their potential physical, intellectual, emotional and social capacity. Strad House is a converted residential property and is located in Wollaston, within a short walking distance of the village, which has a large variety of amenities and facilities. The house is on a main bus route giving access to neighbouring towns. The building comprises of a large communal lounge, dining room and a number of bedrooms (as well as kitchen, laundry, bathroom and toilets) on the ground floor and bedrooms, bathrooms and toilets on the first floor. The home has a shaft lift and other aids and adaptations consistent with the needs of older people. There is some car parking space to the rear of the building. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day between 9.45am and 1.23pm. Due to the ownership of the home being due to change in the near future it was agreed post inspection with the manager that another inspection would be carried out so as to involve the new owner. Methods used to gain evidence including case tracking two residents’ care, discussion with the manager, sampling of numerous records including those relating to the residents, staff and premises. Residents and staff are to be thanked for their assistance with the carrying out of this inspection. What the service does well: What has improved since the last inspection? What they could do better: There are many areas where improvements are required the most serious the observed practice of underarm lifting, the lack of care plans and omissions in some of the recruitment checks carried out by the home. The use of drag lifting was stated by the manager (in writing) to have ceased. The premises need some work in respect of redecoration and general cleanliness. There are other areas that present risk this including falls, use of cot sides and lack of footrests on wheelchairs without risk assessment having being carried out. There were also some assessments that were clearly not up to date. There are also some other areas, not of such serious concern that are detailed within the body of this report. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 6 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. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 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 Strad House DS0000024951.V253243.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents needs are assessed prior to admission, but no written assurances as to the home being able to meet their individual assessed needs is given. EVIDENCE: The resident’s case files were seen to contain copies of social work assessments these not accompanied by a care plan carried out under care management arrangements (via the social worker). The social worker assessments for recently admitted residents had been obtained prior to the residents admission, and there was evidence of the home having carried out its own assessments that drew out and built on the information in the initial assessments. For existing residents there was evidence of on-going reviews by their allocated social worker. The home has not however confirmed to recently admitted residents, that based on assessments the home is able to meet their needs. This written confirmation needs to be sent to prospective residents prior to their admission to the home. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,10 There are no individual plans of care that set out resident’s health, personal and social care needs. There are times when resident’s privacy and dignity are compromised. EVIDENCE: There were only general assessments in place in resident’s case files no care plans, this subject of an immediate requirement. A care plan based on a comprehensive assessment of need must be drawn up with each resident, this to provide the basis for the care to be provided to each individual resident. The manager has responded to the immediate requirement stating that it will be actioned. There was however evidence of a general monthly review of assessments in place (these completed by key workers). There were some more specific assessments seen, these in respect of nutrition and continence although outcomes of these assessments do need to inform the care plans when drawn up. It was also noted that one continence assessment identified a date for update, there being no evidence of whether this had been followed through or not. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 10 There was no evidence of tissue viability assessments, although the necessary precautions to prevent pressure areas was seen to be in place for one resident as necessary, this including the provision of pressure relieving mattress and the like. There was also no evidence of the home having any falls risk assessment in place although again there was evidence of preventative measures (from injury) being in place for one resident (at risk from falls). Some district nurses were stated by one resident to be changing their dressings in the lounge, this confirmed by the manager to happen on occasions. This must not happen and the manager must ensure that the resident’s privacy is maintained. One resident spoken to was quite clear that their privacy was respected with staff knocking her bedroom door before entry, allowing access to bedroom whenever wished etc. Care documentation was seen to contain residents preferred titles, these consistent with names used. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents receive a balanced diet that residents are satisfied with. The home’s menu as on display in the home does not reflect the meals available to residents. EVIDENCE: Nutritional assessments were now seen to be in place, these introduced since the last inspection. Menus were seen to be on display although the meal served at lunchtime did not correspond with this menu. The manager told the inspector to ignore the menus, as they were incorrect and that accurate records of the meals were kept in the kitchen. This is unsatisfactory, as residents need to know what is available. Whilst the cook does ask residents on a morning as to their choice on that particular day, the menus need to be accurate so that they can remind residents of choices available. The main meal of the day looked satisfactory however and a choice was available to the residents. This choice was reflected in the records of meal choices kept by the staff at the home. From these records there was evidence that residents were provided with a balanced diet. Comments from the residents as to the food available was positive with the following comments made: ‘Food very good, have what I want’. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 12 ‘Food is very good, better food than normally at home, do get choice, can ask for different’ Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Residents were unaware of what steps to take to make complaint or raise concerns. The homes practices for transferring residents at the time of the inspection were unacceptable and potentially dangerous EVIDENCE: The home was seen to have a complaints procedure on display in a communal area and details are included in the homes statement of purpose. Residents spoken to were however unclear about the homes procedure in respect of making complaints and the manager was advised to ensure that all residents are made aware of what to do if they have any concerns. The manager stated that she would raise this matter at the next resident’s meeting, this set for early November. There have been no complaints received at the home since the last inspection in March 2005. The home was seen to have policies and procedures in respect of adult protection and related areas. There were some concerns in respect of recruitment practices detailed later in this report. There was concern that staff were underarm/drag lifting one resident, this seen by the inspector. This practice is potentially dangerous and can be uncomfortable or painful for the resident at the very least. This did give rise to an immediate requirement and the written response from the manager indicated that this practice has now ceased, with the use of a hoist instead. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 14 The resident is known to have been referred to the social worker, this so that an assessment can be carried out by an Occupational therapist so as to establish the best method for transfer of this resident. The manager was made aware that any use of this method of lifting is to be seen as potential abuse. It was noted that resident’s case files did not contain any inventories of their property. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,25 The environment needs to be subject to some redecoration and refurbishment. Standards of cleanliness could be better. Residents are generally satisfied with their bedrooms. EVIDENCE: Strad house is an extended and adapted building set in a pleasant residential area with easy access to a nearby shopping centre and bus routes. Stourbridge town centre is a short drive away. The home is in need of some decorative work noticeably the lounge and dining area. The dining area presents as quite dark, this partly due to décor and lighting, this as there is limited access to natural light in this area. The providers have some detail in respects of planned refurbishment in their business plan but this will need to be revised and updated. There would need to be an audit of the carpets within this as these were worn in some areas. The home is due to change ownership and it is recognised that the new owner will have a view as to this issue. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 16 The home has a lawn and car park to the rear of the property. Not all the homes radiators were covered although there was seen to be a risk assessment in place in respect of this matter and the manager stated that all the radiators would be fitted with covers by the end of November 2005 if not earlier. One resident stated that they would like a key to her bedroom locker this not provided to her. All residents should be asked as a matter of course if they wish to hold keys to the lockable drawers in their bedrooms. The same resident also wished to have a telephone in her room and the manager stated that this would be discussed with her family. There were some concerns as to the cleanliness of the home. Various radiator shelves were seen with numerous dried on cup rings on them and some duvet covers seen in bedrooms were stained. The cleanliness of the home must be audited by the manager on a regular and on going basis. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 There are sufficient staff available to meet resident’s needs. Residents are not supported or protected by the homes current recruitment practices. EVIDENCE: The staffing levels on the day of the inspection were satisfactory as the home had a number of vacancies. Based on observation and sight of the staff rota there are two care staff available during daytime with the manager and ancillary staff additional to this. Staffing levels would need to be kept under review when the number of residents increases and vacancies are filled. There are currently two waking night staff, this confirmed by comments from residents. The home has employed one staff member since the last inspection and an audit of the recruitment checks was carried out. There was no application form available, this seen to be a serious omission. Due to the lack of an application form it was not possible to see the staff members working history, full basic details, who referees were etc. All information required by the Care Home Regulations must be obtained prior to employment this including the following (some of which was available at the home): - Proof of the person’s identity (including birth certificate, passport [if any]); Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 18 - Documentary evidence of qualifications; - Two written references – one which must be from the last social care employer; - Evidence that the person is physically and mentally fit to carry out their duties (for example medical questionnaire); - Full working history (on application form) - Evidence of a suitable check through POVA 1st (Protection of vulnerable adults) list. - A statement from the staff member in respect of any convictions in absence of an enhanced disclosure. An acceptable enhanced disclosure must also be obtained, but where there are concerns about maintaining staffing levels it maybe permissible to employ a staff member prior to the receipt of this disclosure if all the other information detailed has been obtained and a risk assessment has been carried out by the manager/provider. This risk assessment must be shared with the CSCI for agreement prior to employment of prospective staff members however. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36, 38 Staff are not supervised at sufficiently regular intervals on a one-to-one basis. There are areas where there needs to be improvement so as to protect the health, safety and welfare of residents. EVIDENCE: The manager at the time of the inspection stated that staff supervision was had not been carried out in accordance with the expectations of the national minimum standards. It was stated in discussion after the inspection that she is focusing on improving input into staff supervisions, this to be revisited at the next inspection. The homes fire risk assessment had been reviewed this year and was well laid out but did not reference the way the risk presented from bedrooms doors Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 20 been left open was to be managed. This needs to be included within this assessment. The home’s accident book, when seen, was found to be recorded in a small bound book although the manager was advised to revise this so that there is a standardised format for staff to complete rather than use of freestyle. There were no particular trends identified from the accidents documented within this record. Risk assessments in respect of other a number of other areas related to safe working practices areas were seen. There were however no risk assessments in respect of the homes use of cot sides. These must be drawn up and identify methods used to reduce any risks such as entrapment and such like. It was noted that some wheelchairs did not have footrests fitted. These must be fitted at all times unless there is a risk assessment identifying valid reasons for this not to happen. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 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 X x 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 X X X 2 2 X STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 2 Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 22 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 OP3 Regulation 14(1) d Requirement Timescale for action 21/11/05 2 OP7 13(4) 3 OP7 15(1) The Registered person must confirm in writing to the service user, prior to admission, that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his/her health and welfare. There must be risk assessments 21/11/05 in respect of falls for all residents where this has been identified as an area of concern. A care plan based on a 03/11/05 comprehensive assessment of need must be drawn up with each resident, this to provide the basis for the care to be provided. This was an immediate requirement. These plans must identify clear action to ensure that all aspects of the resident’s health, personal and social care needs are being met. These (plans) must be drawn up with the resident or their representative who must sign to Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 23 4 5 OP8 OP8 14 13(4)c 14 acknowledge their agreement. Actions identified within continence assessments must be followed up. Tissue viability assessments must be in place for all service users and where present must be accurate. This is a repeated requirement that was to have been met by the 1.5.05. The home must record evidence of access to nursing, dental, chiropody, opticians and hearing aids according to needs as they arise. 21/11/05 03/11/05 6 OP8 12, 13 & 14 03/11/05 7 OP9 13(2) This is a repeated requirement that was not fully assessed but has been partly met. It will be assessed on the date shown. The home must continue to liaise 03/11/05 with the appropriate G.Ps to ensure that there are specific directions for the administration of all service users medication. This is a repeated requirement that was not assessed at the time of this inspection. It will be assessed on the date shown. The manager must ensure that visiting health professionals do not carry out personal care tasks in a communal environment. The home must implement an activities programme in consultation with service users. This must be regularly reviewed. Service users interests must be recorded and where possible residents must be supported and encouraged to pursue stimulation in and outside the 8 OP10 12(4) 03/11/05 9 OP12 4 &16 21/11/05 Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 24 home, which suits their needs, preferences and cultural interests. This is a repeated requirement that was not fully assessed at the time of this inspection. It will be assessed on the date shown. The manager must ensure that 21/11/05 residents are aware of the homes complaints procedure. Inventories of resident’s property 21/12/05 must be maintained. No staff are to use any form of 22/09/05 inappropriate lifting or handling technique that has the potential to cause injury or cause a service user avoidable pain or discomfort (i.e. underarm handling techniques). This was an immediate requirement. The manager/provider must develop a written rolling programme of maintenance for the refurbishment and redecoration of the building that includes those areas detailed within the body of this report The manager must monitor the general cleanliness of the home on a regular basis. The manager must carry out all the checks for new staff prior to employment as detailed within the body of this report including a protection of Vulnerable Adult list (POVA 1st) list check. If the staffing situation dictates that staff are needed prior to receipt of a suitable enhanced disclosure this is permissible (where the home may contravene staffing requirements without the new staff) but only Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 25 10 11 12 OP16 OP18 OP18 22(5) 13(6) 13(4) & (5) 13 OP19 23 21/12/05 14 15 OP26 OP29 13(3) 23(2)d 19 21/11/05 22/09/05 16 OP32 10,18 following discussion of the risk assessment carried out by the home with the CSCI. Staff meetings must take place regularly and staff sign to say they have attended. These must be recorded and kept on file. 03/11/05 17 OP33 24 This is a repeated requirement that was not assessed at the time of this inspection. It will be assessed on the date shown. The home must implement a 03/11/05 quality assurance and monitoring system for seeking the views of service users. This is a repeated requirement that was not assessed at the time of this inspection. It will be assessed on the date shown. Where residents so request they must be provided with keys to lockable drawers in their bedrooms. All radiators are to be fitted with appropriate covers that prevent access to hot surfaces. To implement a formal supervision system, ensuring care staff receive a documented supervision session at least six times every year. This is a repeated requirement One supervision session per annum maybe a training analysis/appraisal for individual staff. Where cot sides are in use a risk assessment must be carried out identifying measures to reduce any potential risks presented. Wheelchairs must be fitted with DS0000024951.V253243.R01.S.doc 18 OP24 16(2)l 21/11/05 19 20 OP25 OP36 23 18 30/11/05 21/12/05 21 OP38 13(4)a 23(2)c 13(4)a 21/11/05 22 OP38 03/11/05 Page 26 Strad House Version 5.0 23(2)c 23 OP38 24(3) 12(2)(3) footrests at all times unless there is a risk assessment identifying valid reasons for this not to happen. The practice of propping open fire doors must cease. This is a repeated requirement. Where doors are held open with appropriate devices then this should be detailed within the home’s fire risk assessment. Liquid soap must be available at the hand washbasin in the laundry at all times. This is a repeated requirement that was not assessed at the time of this inspection. It will be assessed on the date shown. Risk assessments (in respect of individual service users) must be up to date to maximise safety to service users. This is a repeated requirement 21/11/05 24 OP38 13(3) 03/11/05 25 OP38 13 03/11/05 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 OP15 OP24 Good Practice Recommendations The home’s menus should be accurate and reflect the meals on offer accurately at any given time. The manager must audit the furniture and fittings in residents’ bedrooms against those detailed within the national minimum standards and then consult and record residents’ wishes accordingly. DS0000024951.V253243.R01.S.doc Version 5.0 Page 27 Strad House 3 OP38 Accident reports should be recorded on standard formats as opposed to ‘freestyle’. Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 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 Strad House DS0000024951.V253243.R01.S.doc Version 5.0 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!