Inspection on 22/06/05 for Alde House

This inspection was carried out on 22nd June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Alde House 30/04/09

Alde House 02/05/07

Alde House 03/10/06

Alde House 08/02/06

Alde House 17/12/04

Alde House 06/07/04

Alde House 16/01/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Alde House Church Lane Penn, High Wycombe Buckinghamshire HP10 8NX Lead Inspector Mike Murphy Announced 22nd June 2005 9:30am 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 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. Alde House Version 1.10 Page 3 SERVICE INFORMATION Name of service Alde House Address Church Lane, Penn, High Wycombe, Buckinghamshire, HP10 8NX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01494 813365 Stumpwell Housing Association Limited Mrs Violet Bassam Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Alde House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th December 2004 Brief Description of the Service: Alde House is a care home for older people situated in Penn, Buckinghamshire. It has fifteen places. The home was opened in 1972 and is managed by Stumpwell Housing Association Limited. The home has been adapted for its present use and comprises the original house and an extension. There is a large and pleasant garden to the rear with views over the surrounding countryside. The home is on two floors and there is a passenger lift to the first floor for residents with impairment of mobility.The home is mindful of its origins in Penn and priority is given to people who either live in the village, have lived there in the past, or still have family or friends in the area. The home endeavours to meet a range of need and draws on the resources of health and social care professionals and other services in the local community as required. Alde House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted in one day by two inspectors, both of whom were familiar with the home and had conducted earlier inspections. The methodology consisted of consideration of pre-inspection information supplied by the home, meetings with the registered manager and chairman of the committee, meetings with staff, discussions with residents and relatives, consideration of comment cards submitted by relatives and others, review of documents, and a tour of the building and grounds. The home was established in 1972 and is situated in a pleasant semi-rural location on the edge of Penn village, about three miles from Beaconsfield and four miles from High Wycombe. The home is run by Stumpwell Housing Association. The Chairman of the Committee met with the inspectors and the registered manager during the course of this inspection. The home provides accommodation and care for fifteen residents. The home does not offer nursing care. Ten of the fifteen bedrooms provide en-suite (wc and wash basin) accommodation. There are two lounges and a dining room. The garden to the rear of the home offers views over rolling countryside. The statement of purpose has been revised. All areas of the home were clean and tidy and provided a safe environment for residents, staff and visitors. Residents expressed appreciation of the friendly atmosphere, the care provided by staff and the quality of the food. Written feedback from relatives and other sources in advance of the inspection was positive. Alde House Version 1.10 Page 6 As noted in earlier inspection reports there is a strong commitment to care and standards of personal care for individual residents appear good. This good work, however, needs to be supported by more systematic approaches to the assessment of residents needs and care planning, combined with ongoing staff supervision and development. Arrangements for the control, storage and administration of medicines are generally satisfactory but some recommendations are made with regard to further improvements. At the time of this inspection the home had staff vacancies – including that of deputy manager – and some anxieties were expressed that this situation could compromise standards of care. While this is a real possibility evidence was not found on this inspection but the matter needs to be kept under review by managers. When recruiting new staff the home needs to ensure that it complies fully with the regulations. Overall, as in previous inspections, this home provides a good quality service to residents and maintains the confidence of residents and relatives. What the service does well: What has improved since the last inspection? Alde House Version 1.10 Page 7 An ongoing programme of redecoration and refurbishment has led to the following improvements: the fitting of a radiator cover, redecoration of three bedrooms, new carpets to bedroom and sun lounge, re-upholstering of three chairs in tv lounge and new curtains to the flat on the third floor. New washing machine in laundry room. New microwave in kitchen. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alde House Version 1.10 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Alde House Version 1.10 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 5 Prospective residents and their relatives have up to date information on the home to inform a decision on accepting the offer of a place. The process of assessment aims to ensure that only people whose needs it can meet are offered a place. The needs of residents are assessed and recorded by experienced staff and provide a basis for the formulation of a plan of care. Prospective residents may visit the home and move in on a trial basis in order to decide whether it can meet their needs and that they are happy to reside there. EVIDENCE: The statement of purpose has been revised since the last announced inspection. This is set out in a clear and easy to read typeface and includes a statement of the philosophy of the home, details of the management committee of Stumpwell Housing Association (the registered provider which owns and runs the home), a statement on quality assurance, details of staffing (including the experience of the manager), a description of the accommodation Alde House Version 1.10 Page 10 (but not the size of rooms), the admissions policy and procedure, assessment, discharge, dying and death, financial arrangements, an overview of health & safety and protection of vulnerable adults policies, times of meals, activities, the policy on visitors, policy on complaints, and the residents charter. Attached to the copy submitted for the inspection was, the complaints procedure, a copy of the application form, a copy of the guarantee contract, a copy of the contract, and of the ‘acceptance for temporary residence’ form. In the form outlined above this provides almost all of the information required under Schedule 1 of Regulation 4(1)(c) with the exception of the arrangements for consultation with service users, the fire precautions and associated emergency procedures and the size of rooms. The complaints procedure also requires review (see evidence under standard 16 below). The contract is a three page document which includes the number of the room to be occupied, the service to be provided, fees payable, services for which additional fees are payable, the obligations of the resident and of guarantors, and the period of notice. The document does not include reference to liability should a breach of contract occur. The statement of purpose outlines the home’s policy and procedures for assessing needs. Enquirers receive a booklet and price list and may view the home by arrangement. If they wish to pursue the enquiry then an assessment of the prospective service user is arranged. This is conducted by the registered manager and a member of the management committee. This takes into account any available information from health and social care professionals. New residents may have a month’s trial stay which can be extended if necessary. At the end of this time both parties are in a position to say whether the home can meet the person’s needs. The home liaises with other professionals – mainly GPs and district nurses - as required. Alde House Version 1.10 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Standards of care planning are uneven and may not fully record residents needs. Staff skills in care planning (as assessed indirectly through examination of care records) need further development if the home is to ensure that residents needs are recorded and are fully met. The home maintains effective liaison with local health services and endeavours to ensure that healthcare needs are met. Systems for the storage and administration of medicines are good and reduce the potential for errors in medication to occur. Residents are treated with courtesy and respect and the home provides opportunities for personal care to be provided in private, thus maintaining individual dignity. EVIDENCE: The format of care plans was under review at the time of this inspection. New care plans under consideration by the manager appeared to have significant Alde House Version 1.10 Page 12 advantages over those currently in use. A programme of staff training and supervision should accompany the introduction of any new system. Three care plans were examined. Care plans include a ‘pen picture’ of the resident which is useful. Assessments and care plans covered a range of subjects. The quality of recording assessments varied. Most were comprehensive but tended to focus on physical aspects of care. Moving and handling assessments were in place where indicated. Records of care provided did not appear to include reference to the assessment and care plan. For example in the case of someone with depression daily records did not include reference to the person’s thoughts, feelings, interests or participation in activities. Some sections were undated and unsigned and a review date was not recorded. One record had large sections left blank. Records may not reflect the range of care provided. The home liaises with other professionals and health services as required. All service users are registered with a general practitioner. Service users appeared well cared for and expressed a high level of satisfaction with care provided. Access to chiropody and opticians is available by appointment. A range of NHS healthcare services are accessed through the GP. Service users are weighed monthly. Some areas of the home are adapted to maintain mobility as necessary. Arrangements for the maintenance of privacy and dignity appear satisfactory. One living area has access to the rear garden. The home uses the Boots Manrex monitored dosage medication system. A pharmacist carries out a quarterly audit of medication and the home receives a written report. The medication administration (MAR) sheets were examined. Sheets were appropriately completed and no gaps were noted. However, handwritten entries of prescribed medication on MAR sheets did not have two staff members’ signatures and were not signed and dated. Consistency is needed to ensure that where a medication is discontinued or a course of antibiotic treatment completed the person writing on the MAR sheet should date and sign the entry. As a good practice it is recommended that protocols be developed for the administration of Warfarin and Fosamax medication. It is also recommended that where residents are prescribed a variable dosage of painkillers (such as paracetamol or Co-codamol) the dosage or number of tablets administered be recorded on the MAR sheet. A list of the names of staff who administer medication, together with samples of their signatures, should be kept in the medication folder. Alde House Version 1.10 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 The home organises a range of activities which support residents participation in social activities. A Christian service is held weekly to meet the needs of residents wishing to express their religious faith. The home provides meals of a good standard which are much appreciated by residents and which contribute to the maintenance of good nutrition. With the residents permission visitors are welcome at any time which is of benefit to both the resident and the visitor in maintaining contact with family and friends and for the resident in maintaining interest in events outside the home. EVIDENCE: Residents spoken to confirmed that they are able to rise and retire when they wished. Up to date information on activities was not on display in the home. Some anxieties were expressed with regard to the impact of staff shortages on the range of activities provided. A weekly outing to a pub or place of interest is arranged. On the day of the inspection some residents went out on an outing to a pub for lunch, which on return they said they thoroughly enjoyed. A weekly religious service is held in the home and every other week favourite hymns are sung. Staff also arrange board games, crosswords and movement and music exercise for residents. The daily log for each resident, however, Alde House Version 1.10 Page 14 does not include a record of attendance or participation in activities and staff should ensure that this information is recorded. Residents were complimentary about the meals and made the following comments: “The food is very good”, “the food is delicious, it is like being in a three star hotel,” “the food is excellent, there is variety, cakes are home made.” The home provides three meals daily with snacks and hot and cold drinks being available as required at other times. The inspectors joined residents for lunch, which was of good quality. The menu consisted of roast chicken with stuffing, roast potatoes, sliced green beans and swede. Dessert was fresh fruit salad with cream. Tables were set with appropriate cutlery, condiments and place mats. Residents were offered cold drinks with their meal as well as a tea or coffee afterwards. Lunchtime was relaxed and staff assisted residents as required. Residents are able to have visitors at any time within reason and are able to choose whom they wish to see. Visitors are able to meet with residents in the lounge or in residents’ bedrooms in private if they wish. Resident said that staff make their visitors feel welcome and offer refreshments when required. The home has close contact with the local church and volunteer groups. On the day of the inspection some residents had visits by relatives or friends. Alde House Version 1.10 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 The home has a complaints policy and procedure which ensures that complaints are dealt with promptly. Residents are registered on the electoral register which allows them to vote if they wish. The home has a policy and staff training programme on adult protection which ensures that staff are aware of the issues and that residents are protected. EVIDENCE: The home has a simple and straightforward complaints procedure which was reviewed in May 2005. However, the procedure states that ‘If a complaint remains unresolved then it may be passed on to CSCI…’ and ‘…but this should not occur until internal procedures have been exhausted without reaching a satisfactory conclusion’. This is incorrect: a complaint may be referred to CSCI at any stage. It goes on to say that if the complaint remains unresolved then it should be referred to the CSCI regional office in London. This is not quite correct. A complaint to the CSCI regional office is more likely to be about the quality of the CSCI investigation of the original complaint than about the complaint itself. The procedure includes an assurance that the home ‘…will respond to all complaints within 28 days’. Residents are registered on the election register. A notice informing residents and their relatives about how they could access the services of an advocate was displayed in the home. The home has a policy on adult protection and abuse. A basic internal training programme on abuse awareness has been Alde House Version 1.10 Page 16 established. The manager was due to attend external training in October 2004. Weaknesses in recruitment procedures with regard to ‘POVA first’ checks in advance of an enhanced CRB certificate need to be corrected (see standard 29 below). Arrangements for managing residents monies appeared satisfactory and are managed by the manager and the administrator. Records are retained. The home does not act in any legal capacity for residents. Alde House Version 1.10 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,22, 23,24, 26 The home is well maintained and provides a pleasant and accessible environment for residents. Standards of maintenance in all areas are good and the home maintains a hygienic and safe environment while providing a homely atmosphere for residents and visitors. EVIDENCE: The home is accessible, safe and well maintained to meet residents’ needs. The home has a programme of routine maintenance. Renewal of the fabric and decoration of the premises is carried out over the course of the year. Since the last announced inspection a programme of redecoration and refurbishment has led to the following improvements: the fitting of a radiator cover, redecoration of three bedrooms, new carpets to bedroom and sun lounge, reupholstering of three chairs in tv lounge and new curtains to the flat on the third floor. New washing machine in laundry room. New microwave in kitchen. Alde House Version 1.10 Page 18 The home’s maintenance man ensures that footpaths and flat roofs are free from build up of moss and weeds. Grounds were tidy and well maintained. There are no outstanding requirements in relation to the physical environment of the home or to fire safety issues. The home has two sitting areas and a dining room. Residents are able to meet visitors in private in their bedrooms if it is their wish or may use one of the sitting rooms or a small seating area in the lobby. Lighting and furnishings in the communal areas were in a good condition. The home has an adequate number of bathrooms and toilets close to bedrooms and living rooms to meet residents’ needs. Some bedrooms have en-suite facilities. Residents are provided with specialist equipment such as wheelchairs and Zimmer frames to promote independence. Bathrooms are fitted with hoists to assist staff helping residents with bathing. Raised toilet seats are available in some toilets. Mobile hoists are also available to assist with moving and handling. Grab rails and handrails are installed in corridors and in some residents’ bedrooms where necessary. There is also a passenger lift and ramp installed so that residents have access to bedrooms and communal areas. Bedrooms were clean, tidy and personalised with family pictures, mementoes and small pieces of furniture and reflected the characters of individuals. Lockable storage space was available for residents to lock away valuables. Bedroom doors were lockable. Residents said that their rooms were very comfortable and praised staff for maintaining them to a high standard. All bedrooms are centrally heated and radiators in bedrooms are covered. Lighting is domestic in character and conforms to current standards. Emergency lighting is provided throughout the home. Hot water taps in residents’ bedrooms and communal areas have been fitted with restrictor valves to prevent scalding. Water temperatures in some hot taps were checked and were within safe limits i.e. close to 430 Celsius. The laundry is situated away from areas where food is prepared or stored. There are two washing machines and one drier. Walls in the laundry room were free from dust and it was evident that a cleaning schedule was in place and being adhered to. Red alginate bags were available for soiled linen and hand washing facilities were available. It was noted that waste bins had swing top bins. It is being recommended that they should be replaced with foot pedal bins. On the day of the inspection the home was clean, pleasant, hygienic and free of offensive odours. Alde House Version 1.10 Page 19 Alde House Version 1.10 Page 20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 While the number of staff is adequate for the present number and dependency level of residents, at the time of this inspection the home had some vacancies and concerns were expressed at the potential impact of this on the overall quality of the service. The home maintains a training programme addressing NVQ and health & safety training which aims to ensure that care is provided by trained staff. Staff recruitment procedures are generally sound but inconsistencies in obtaining POVA first checks in advance of an enhanced CRB certificate exposes residents to risk. EVIDENCE: The staff establishment has not changed since the last inspection. A copy of the duty rota is available in the home and was submitted for the inspection. The present staff establishment maintains two care staff and the manager in the morning, two care staff in the afternoon plus one additional care worker covering the twilight shift and one waking and one sleeping member of staff at night. Staffing calculations are not based on the Residential Forum staffing tool. At the time of this inspection the home had some vacancies including that of deputy manager. The manager was not supernumerary. Some anxieties were expressed at the effects of staff shortages on staff continuity, the ambience of the home, the range of activities and the overall quality of care. There are no staff aged under 21 providing personal care. In addition to care staff the home employs two part-time domestic staff, a part-time cook, a parttime administrator and a part-time handyman. Alde House Version 1.10 Page 21 According to information supplied by the home two care staff have NVQ2 qualifications and three were doing NVQ2 at the time of this inspection. One is awaiting a place on a course. Vacant posts are advertised in local newspapers. Two staff files were examined. Two references had been received in each case. Precise dates of former employment were not on either application. One person had commenced employment six weeks before a POVA first check had been obtained. Staff were aware of the GSCC codes of practice. Staff induction is not to TOPSS (now ‘Skills in Care’) standards and the manager undertook to obtain a copy of that programme. The staff training programme for 2005 consists of updates on first aid, abuse, challenging behaviour, moving & handling, use of the hoist and sling, and health & safety. Dates for training sessions in fire prevention and medication are to be confirmed. Alde House Version 1.10 Page 22 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Arrangements for maintenance and health & safety procedures in all areas are generally good which ensures that the home provides a safe environment for residents, staff and visitors. The home is currently unable to ensure that a first aid trained member of staff is on duty at all times which potentially exposes residents to delay in receiving treatment in the event of acute illness or accident. EVIDENCE: Fire records examined confirmed that the fire panel is checked weekly. Records indicated that fire zone areas are regularly activated and that regular fire drills take place. Records indicated that during the most recent fire drill residents and staff evacuated the building in four minutes. As a good practice the names of staff members participating in fire drills should be recorded. Alde House Version 1.10 Page 23 Food temperature and fridge and freezer records examined were satisfactory. The inspectors were told that all staff had undergone first aid training. As a good practice it is being recommended that a first aider should be designated on each shift. Alde House Version 1.10 Page 24 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 2 x x x x x x x x Alde House Version 1.10 Page 25 Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action 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. 3. 4. 5. Refer to Standard 7 16 36 9 9 Good Practice Recommendations It is recommended that the registered manager review the system of care planning and care plan records to address weaknesses in its present systems It is recommened that the registered manager review the complaints policy and procedure to ensure compliance with this standard It is recommended that the registered manager establish a programme of personal supervision for care staff It is recommended that the registered manager develop written protocols governing the administration of Warfarin and Fosamax. It is recommended that where a resident is prescribed a variable doe of analgesia or other medicine that the precise amount administered is recorded on the MARS sheet. It is recommended that the recording of medicines on MARS sheets transcribed from medical prescriptions be signed and dated by two members of staff It is recommended that a list of the names and signatures of staff approved to administer medicines be retained in Version 1.10 Page 26 6. 7. 9 9 Alde House 8. 9 the medicines folder It is recommended that where a course of medicine is completed or discontinued that an entry to that effect is made on the MARS sheet and that this be signed and dated. Alde House Version 1.10 Page 27 Commission for Social Care Inspection 8 Bell Business Park Smeaton Close Aylesbury Buckinghamshire HP19 8JR 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 Alde House Version 1.10 Page 28 - 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!