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Inspection on 15/12/05 for Acton Care Centre

Also see our care home review for Acton Care Centre for more information

This inspection was carried out on 15th December 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Registered Manager and the General Manager provide effective management of the home and leadership for the staff. The Inspectors observed that staff were working well together as a team in meeting service users needs. Information provided about the home to service users and representatives is up to date and comprehensive and provides a very clear picture of the facilities the home provides. Complaints are well managed, and there have been no POVA issues since the last inspection. There was evidence of input from Healthcare professionals and good multi-disciplinary working practices. The food provision is good, and service users spoken with expressed their satisfaction at the food quality and choices given. The training provision for staff is good and encompasses health & safety plus other training required to meet service users general and specialist care needs. Infection control is well managed in the home. Auditing systems for quality control are good and any shortfalls identified are addressed promptly. There are robust systems in place for the management of service users personal monies. The servicing and maintenance systems in place are comprehensive and are well managed.

What has improved since the last inspection?

The home had worked hard to meet the requirements from the last inspection, and few additional shortfalls have been identified at this inspection. It is clear that the home is well managed and this cascades to the units, with the staff teams working together to attain and maintain a good standard throughout the home.

What the care home could do better:

Some shortfalls identified with the service user plans should be easy to address. Generally the medications are well managed, but the shortfalls identified are significant and must be addressed robustly. There is an ongoing issue with lack of storage within the home, which requires clear planning to address, as it is acknowledged that currently there is no additional storage space available within the home. Minor shortfalls in the staff records have reoccurred, and the system needs to be maintained accurately to ensure all required checks on staff are completed prior to employment. Staff supervision is in place, with some additional work to cover all aspects and to ensure a minimum of 6 sessions per year for all staff providing care.

CARE HOMES FOR OLDER PEOPLE Acton Care Centre 48 Gunnersbury Lane Acton London W3 8EF Lead Inspector Mrs Clare Henderson Roe Unannounced Inspection 09.30 15 & 19 December 2005 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Acton Care Centre DS0000034968.V261636.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. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Acton Care Centre Address 48 Gunnersbury Lane Acton London W3 8EF 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) 0208 896 5600 0208 992 7116 Vintage Care Ltd. Mrs Sujjata Singh Care Home 125 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0), of places Terminally ill over 65 years of age (0) Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered to provide nursing care for 71 service users over the age of 65 and for general nursing care for 54 service users with dementia over the age of 65. Of these 4 service users may be terminally ill. The home must ensure that staff working with terminally ill service users are Registered Nurses with appropriate post qualification training in the care of terminally ill. One named service user under the age of 65 years may be accommodated, as agreed by the Commission For Social Care Inspection, on 24th August 2005. The home must advise the CSCI when the service user no longer resides at the home. 13th June 2005 2. 3. Date of last inspection Brief Description of the Service: Acton Care Centre was registered in March 2003 to provide nursing care for 125 service users over the age of 65. The home provides 71 beds for general care and 54 beds for dementia care. At the present time 4 beds are also registered for palliative care. It is a purpose built home with modern amenities close to Acton High Street set on the site of the old Acton Hospital. All the bedrooms are single with en suite facilities. The home has recently had 5 assisted baths fitted, and this has improved the bathing facilities in the home. The home is able to access other health care professionals to supplement the nursing care already provided. The home has a large car park at its front and landscaped gardens at the rear of the building. At the time of inspection there were 98 service users accommodated at the home. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 21 hours was spent on the inspection process. The Inspectors carried out a tour of the home, and inspected service user plans, staff records, financial records, maintenance and servicing records. 7 service users, 6 staff and 8 visitors were spoken with as part of the inspection process. The purpose of this inspection was to follow up the requirements and recommendations from the last inspection, and to view some additional standards. The majority of key standards were viewed at the last inspection and it is recommended that this report be read in conjunction with the last report to gain full inspection information for the home. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia care needs. What the service does well: What has improved since the last inspection? The home had worked hard to meet the requirements from the last inspection, and few additional shortfalls have been identified at this inspection. It is clear that the home is well managed and this cascades to the units, with the staff teams working together to attain and maintain a good standard throughout the home. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 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. Acton Care Centre DS0000034968.V261636.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 Acton Care Centre DS0000034968.V261636.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): 1, 2, 3 and 4. The home does not provide intermediate care. Service users and their representatives are provided with information about the home. Written agreements are available for each service user, thus providing clear information about the services provided. Service users are assessed prior to admission to ensure the home can meet their needs. Staff have received training and have experience to ensure that they are able to meet any specialist care needs of the service users. EVIDENCE: The home has a Statement of Purpose and a Service User Guide, both of which are up to date and provide comprehensive information. In addition a new brochure has been produced, which provides good information also. The home has specific contracts for each service user. Contracts for privately funded, Social Services funded and Primary Care Trust funded service users were viewed and these were clear and up to date, and had been signed on behalf of the service user and also on behalf of the home. Samples of pre-admission assessments were viewed and these were comprehensive and gave a good picture of the service users assessed needs. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 9 Some of the service users on the general nursing care units had a diagnosis of confusion. However, their physical care needs outweighed any mental health care needs, and it was clear that the staff were experienced to meet their care needs appropriately. The need to ensure that service users are appropriately placed was discussed, and it was felt that there were no issues at this time. This will be kept under review. Staff with dementia care training and palliative care training are available on the units who accommodate service users with such diagnoses. There was evidence of specialist training for staff to enable them to manage service users with specific healthcare needs, for example, tracheostomy care. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 The service user plans are generally well formulated and updates take place, thus ensuring that the information required by staff to meet the service users needs is clear and up to date. Shortfalls identified should be easy to address. Although medications are generally well managed in the home, the shortfalls identified potentially place service users at risk. Staff are courteous to service users and personal support is provided in such a way as to promote and protect the service users privacy, dignity and independence. Service users needs in respect of death and dying are being met, thus ensuring that the service users final days are comfortable and appropriately managed. EVIDENCE: The Registered Manager informed the Inspectors informed the Inspectors that a new system of care planning was being introduced. Service user plans were sampled on each unit. Overall these were comprehensive and gave a good picture of the individual service users needs and how these are to be met. There was evidence that service users families and representatives had been involved in the formulation of the service user plan. Reviews were taking place and the majority of care plans were being updated. Falls risk assessments were in place, and there was evidence that these were being reviewed following any falls. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 11 Generally the wound care documentation was comprehensive and up to date. Pressure relieving equipment in use was identified in each service users plan. On Donald Sword unit, for one service user, a pressure sore had been identified but a care plan for the wound was not formulated until 3 weeks later. The pressure sore risk assessment for the service user did not identify that there was a skin break, and the overall risk score was inaccurate. Although significant, this service user plan was the only shortfall in relation to wound care found. Moving & handling assessments were in place and identified the equipment to be used. Continence and nutritional assessments were in place. Risk assessments for the use of bedrails had been formulated and written consents obtained. In one instance on Oaks unit, a risk assessment for the use of a wheelchair lapstrap had not been carried out, and the relevant care plan required updating to reflect the use of bedrails and a lapstrap. In addition, there had been a change in the personal care giving needs for one service user and this was to be reflected clearly in the service user plan. On Park unit one bedrail consent could not be located, although the registered nurse knew one had been completed and said that this would be addressed promptly. There was evidence of input from health care professionals, and this had been reflected in the service user plan. There was evidence that service user plans had been updated following a re-assessment by healthcare professionals, for example, the Speech & Language Therapist. The CSCI Pharmacist Inspector carried out an inspection on 15/12/05 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were seen to speak with service users in a respectful and courteous manner, and were engaging with service users, for example, one member of staff was reading to a service user. There was a good atmosphere on each unit in the home and staff were also heard being courteous to each other. Service users clothing is individually labelled, and bedrooms viewed were personalised, which is encouraged. Some of the service users on Garden unit had keys to their room, and this is arranged for any service user who wishes to have a key and able to manage. The home is registered to accommodate 4 service users with palliative care needs. Information regarding the wishes of service users in relation to death and dying is recorded, and where the family or service user have not yet wished to discuss this topic, this is clearly recorded. The home has access to the Macmillan Nurse Specialist team. Care planning to meet the needs of service users with palliative care needs are formulated and the management and staff at the home are aware of the needs of service users and their loved ones. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and aspects of 15 Information regarding service users hobbies and interests is available and activities are provided to meet the service users needs. Service users rights are respected and advocacy services can be arranged to provide independent representation for service users. Dietary needs of service users are well catered for with food choices provided and food available that meets service users preferences. EVIDENCE: Care plans and an activities diary have been formulated for each service user. These were seen for all but one service user, and the registered nurse said that this would be addressed promptly. There was evidence of festive activities in addition to the usual activities programmes for the home. The home has access to First Voice Advocacy services. The General Manager said that most of the service users are on the electoral role, and the need to ensure all service users are on the electoral role was discussed. At the last election several service users made postal votes, and others attended the local polling station to vote. Service users were seen to be enjoying their lunch and choices were available. The Inspectors sampled one of the meat plus the vegetarian lunch choices and Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 13 the vegetables. The meals were well presented and tasty. This standard was looked at in depth at the last inspection. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a clear complaints procedure in place to address any concerns raised by service users and their visitors. Systems are in place for the protection of vulnerable adults so as to protect them from possible risk of harm or abuse. EVIDENCE: The home has a clear complaints procedure, which includes timescales and also contact details of the CSCI. There had been 12 complaints since the last inspection, and there was clear correspondence relating to each complaint. The home follows the Ealing Protection of Vulnerable Adults (POVA) procedures. There have been no POVA issues since the last inspection. Acton Care Centre DS0000034968.V261636.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, 21, 22 and 26 The standard of the environment within this home is good, providing service users with an attractive place to live. There is an ongoing issue with storage, which a robust solution needs to be found in order to maintain the homely look and minimise any risks to service users and staff. The home was clean and systems for the prevention of the spread of infection were being adhered to, thus safeguarding service users. EVIDENCE: The home is purpose built. Throughout it was well maintained, clean and smelled fresh. There is ongoing maintenance and a programme for renewal and decoration is being set up in conjunction with a premises audit. Regular environmental audits are undertaken, both internally and externally. The grounds viewed were well maintained and overall the home is welcoming. Since the last inspection 5 assisted baths have been installed. This process has taken time, due to the problems posed by the under floor heating, but these Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 16 issues have been overcome. This has provided a big improvement in the bathing provision within the home. All the shower facilities are assisted. There are still issues with storage within the home, with vacant rooms, bath and shower facilities noted to be being used as storage areas. This is an ongoing problem and continues to be kept under review. It is acknowledged that the building itself does not easily allow for the addition of more storage facilities, so strategic alternatives will have to be sought. The home has good infection control procedures in place, which are put into practice on an ongoing basis, for example, the use of cleansing hand rubs, which are available throughout the home and are used by visitors and staff alike. Protective clothing to include gloves and aprons are available on each unit. At this inspection, there was no evidence of personal toiletries being left in the bath and shower areas viewed. Acton Care Centre DS0000034968.V261636.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 and 30 The home is appropriately staffed to meet the needs of service users. Shortfalls in the staff recruitment procedures could potentially put service users at risk. Staff undergo training to provide them with the skills to meet the needs of the service users. EVIDENCE: At the time of inspection the home was staffed appropriately to meet the needs of the service users. The staffing skill mix has recently been reviewed, and is being kept under review on an ongoing basis, in line with service user dependency. One Inspector viewed three sets of staff employment records. In one instance only one written reference had been obtained. For another member of staff no health questionnaire was seen. The other checks required under the Care Homes Regulations 2001 had been obtained. There was evidence that work permits had been sought for service users where applicable. There was evidence of ongoing training for staff. There was evidence of recent training to include cardiopulmonary resuscitation & anaphylaxis, first aid, tracheostomy care training. Training is provided prior to the home accepting service users with any specialist care needs for which training has not already been provided, for example, for the care of a service user on a respirator. New care staff are provided with the induction and foundation training booklets, which are based on the Skills for Care (formerly TOPSS) core standards. The completion of these programmes will be viewed at the next inspection. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 18 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): 33, 35, 36, 37 and 38 Auditing procedures ensure that the home is well maintained and the views of service users and their representatives listened to. Service users monies are well managed and secure procedures are in place. Records are securely stored in the home and kept up to date, providing current information for service users. Staff receive supervision, and more work is to be done to ensure practice review and personal development needs are included in this process. The health and safety management in the home is robust and safeguards service users, staff and visitors. EVIDENCE: The General Manager has completed Quality Assurance Strategy document to evidence the audits undertaken for quality assurance in the home. The results of the 2005 service users and relatives survey include an action plan to address any shortfalls identified. The maintenance man was in the process of carrying out an audit of all areas of the home to show the current condition of each area and for future planning of redecoration and refurbishment purposes. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 19 The Human Resources policies and procedures have been updated in the past few months. The nursing and clinical procedures were updated last year. The General Manager reported that the Health & Safety policies and procedures are in the process of being updated. Updates to policies and procedures take place every 2 years unless there is a change required in the interim period. Samples of the systems in place for the management of service users personal monies were viewed. There is a robust system in place, with all income and expenditure being recorded and receipts retained for all purchases. Copies of any cheques received for payments are kept. Small amounts of individual monies are stored securely within the home. It was noted that where a service user had run out of money, the home had temporarily funded expenditure such as hairdressing, to ensure the service user did not lose out on this. Letters are written to the representative responsible for managing the service user’s personal money to request additional funds whenever necessary. The Patients Affairs Officer maintains good administration systems for all the areas of work within her remit. Samples of clinical supervision records were viewed. Clinical topics are identified and discussed in one-to-one sessions. The importance of including general supervision as well as clinical supervision was discussed, and the Registered Manager said that she will work towards the provision of supervision of 6 times per year for all staff providing care. Overall records are well maintained and stored securely within the home. The service user plans are kept in the service users bedrooms, with the signed agreement of the service user or their next of kin, so that they are easy for staff to access and use. All staff have attended health & safety training to include fire safety and moving & handling. Recent food hygiene training had been carried out to include new staff. The servicing and maintenance records were viewed. These were comprehensive, up to date and evidenced a high standard of management. A contract company carries out monthly maintenance and servicing works within the home. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 20 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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 2 X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 2 3 3 Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 21 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 2 Standard OP8 OP8 Regulation 17(1)(a) 17(1)(a) Requirement A care plan for wound care must be formulated as soon as a wound is identified. The pressure sore risk assessment scores must be completed accurately and the correct scoring recorded. Risk assessments must be carried out for the use of wheelchair lapstraps. Consents for the use of wheelchair lapstraps and for bedrails must be in place in the service user plan. Medicines must be accurately recorded when administered. MAR sheets must be kept for all medicines prescribed in the home. If medicines are not administered the correct endorsement must be used. Controlled Drug records must be kept accurately and controlled drugs applied as prescribed. A report for the investigation into the shortfall identified at the time of inspection must be forwarded to the CSCI. DS0000034968.V261636.R01.S.doc Timescale for action 01/01/06 01/01/06 3 OP8 13(7) 01/01/06 4 OP9 13(2) 01/01/06 5 6 OP9 OP9 13(2) 13(2) 01/01/06 06/01/06 Acton Care Centre Version 5.0 Page 22 7 OP9 13(2) 8 OP22 23(2)(l) 9 OP29 19 10 OP36 18 When controlled drugs are disposed of the record in the CD register must be signed and witnessed. Adequate designated storage facilities must be available. (previous timescales of 01/04/05 & 01/08/05 not met) A strategic action plan to show how the home is to provide the required storage facilities must be forwarded to the CSCI. All records required under Schedule 2 of the Care Homes Regulations 2001 must be in place. (previous timescale of 01/07/05 not met) Staff must not be employed until all required checks have been completed. There must be evidence that all staff providing care receive formal supervision a minimum of 6 times per year. An action plan to address this must be put in place. 01/01/06 01/02/06 13/01/06 01/02/06 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 OP9 OP9 Good Practice Recommendations That the balances of Controlled drugs are checked daily in Westerly unit. That the home is consistent in recording receipts of medication. Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Acton Care Centre DS0000034968.V261636.R01.S.doc Version 5.0 Page 24 - 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!