Inspection on 15/11/05 for Alexandra House

This inspection was carried out on 15th November 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

Alexandra House 17/06/08

Alexandra House 19/06/07

Alexandra House 28/07/06

Alexandra House 08/06/05

Alexandra House 06/01/05

Alexandra House 09/08/04

Alexandra House 10/03/04

Similar services:

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 Alexandra House Masons Court Hillborough Road Solihull West Midlands B27 6PF Lead Inspector Lisa Evitts Unannounced Inspection 15th November 2005 08:45 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 Alexandra House DS0000004516.V265246.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. Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Alexandra House Address Masons Court Hillborough Road Solihull West Midlands B27 6PF 0121 245 1081 0121 707 1090 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) Sir Josiah Mason`s Trust Mrs Hilary Lloyd Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2005 Brief Description of the Service: Alexandra House is a registered care home for older people. The home is located on the outskirts of Solihull, in a residential area, close to local amenities and a bus service, which provides access to surrounding areas. The home is a single storey building, registered for thirty-six beds, all rooms are for single occupancy. The home has two lounges, two areas for dining and a conservatory, there are four assisted bathrooms and one walk in shower room available plus toilets within close proximity to communal areas. There is level access for wheelchair users to the front entrance and throughout the home. An accessible well maintained garden area with a pond is provided. The home is approached through security gates where there is ample parking for visitors, alternatively there is ample off road parking. The organisations head office is on site, the complex also provides sheltered housing and domiciliary care from separate facilities. Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by one inspector over a morning and lunchtime, and was assisted throughout by the Registered Manager. There were 33 residents living at the home on the day of the inspection. Information was gathered from speaking to the residents and from observing and speaking to the care staff perform their duties and examining care and medication records. A partial tour of the home was conducted. This is the second statutory inspection for the 2005/2006 year and it is recommended that this report is read in conjunction with the previous report. No immediate requirements were required at this inspection. What the service does well: What has improved since the last inspection? The home has introduced nutritional and pressure sore risk assessments, which assist in ensuring the residents , receive the care that they require. A professional visit list has been implemented to assist in recording the information from visiting healthcare professionals. Many of the requirements from the last inspection have been completed and the Manager is keen to address outstanding requirements. Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 6 Odour control throughout the home has improved and the home was found to be clean and fresh on the day of the inspection. The staff have attended various training courses and the home has plans for further staff training sessions, which are extra to the mandatory sessions the home provides. This ensures that staff have the knowledge to perform well in their roles as care assistants. 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. Alexandra House DS0000004516.V265246.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 Alexandra House DS0000004516.V265246.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, 4, 5 Residents are invited to spend a day at the home, enabling them to make a choice about whether or not they may wish to live in the home. Residents know before admission that the home can meet their care needs through the assessment process. Residents are issued with a contract to ensure that they are informed of terms and conditions of their stay at the home. EVIDENCE: The home has a service user guide and statement of purpose, which have recently been updated and these contain relevant information about the home. Each resident is issued with a statement of terms and conditions of residency and this includes the room number to be occupied and trial periods. Two files were reviewed and while both files had a contract in place, the most recent admission into the home had not signed the contract and the manager must ensure that the resident or a representative signs all contracts. Comprehensive pre admission assessments are completed prior to the resident being admitted into the home and this ensures that the home is able to meet the needs of the resident. Residents are encouraged to visit the home and Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 9 have a meal prior to making a decision about whether they would like to live there. One resident had been at the home previously on respite care and stated that she was “very involved in the decision to come into Alexandra House” The manager sends a letter of offer of residency to each resident once the assessment process is complete and she is satisfied that the home can meet the residents needs. Alexandra House DS0000004516.V265246.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 Resident’s health and personal care needs are generally well met by the care staff. Improvements have been made to written care plans; however require further development to ensure they include sufficient detail so that the residents receive good continuity of care. Further improvements are required to ensure that medication is administered in a safe manner and in accordance with the presenting officers information. EVIDENCE: Each resident had a separate set of care plans; some improvements have been made since the last inspection as some personal preferences had been recorded. However the care plans require further development to ensure that they are updated with changing care needs and care plans must be written in respect of challenging or aggressive behaviour to ensure that staff have guidelines on how to deal with the situation. Care plans are generally evaluated on a monthly basis with the exception of the most recent admission into the home, who had not had the care plans reviewed since admission. Care plans are evaluated but the changes to care requirements are not reflected in the actual plan of care, and this does not ensure that the staff have Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 11 the correct information to ensure that residents needs are met and that they receive good continuity of care. Key worker notes on both files reviewed were very detailed. One pre admission assessment had identified a history of falls and this was not reflected in the care plan. Since the last inspection the home has introduced the use of a nutritional risk assessment and the Norton Score to assess the risk of pressure sore development. Manual handling risk assessments were documented and evaluated. Daily reports were found to be very detailed and included information about activities participated in and visits from external healthcare professionals. Daily reports are now written three times a day as recommended at the last inspection. There was evidence that residents had access to visiting healthcare professionals and this included Chiropodist, Optician, District Nurse and phlebotomist. There was also evidence that specialist nurses had been requested to review residents with regards to Parkinson’s disease. The home has implemented a “Professional visit list” to aid with the monitoring of information. One file was seen to have Tippex correction fluid in several places and this was brought to the manager’s attention at the time of the inspection, any mistakes are required to be crossed out and initialled. All files now have details of whether the resident wishes to have a key to their bedroom door. The management of medication was generally good, with the exception of *Prescription ointments not being signed for after administration *The actual amount of variable dosage medications is not recorded *No identity photographs with the MAR charts *Antibiotics are not signed in for on receipt into the home Since the last inspection the manager has commenced some auditing for medication, however this requires further development to ensure that staff are administering medication as prescribed. Alexandra House DS0000004516.V265246.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, 13, 14, 15 Residents are able to exercise their choice over their daily lives and the activities that they choose to participate in, which promotes their individuality and independence. Residents receive a varied and wholesome diet, which meets any specific dietary needs. EVIDENCE: There are a range of activities on offer for residents to participate in should they choose to, and this includes bingo, movement to music, whist, sing a longs and the home was holding a coffee morning on the day of the inspection. In the afternoon staff were observed to be asking residents if they wished to join in the bingo. There was a visible notice board in the main lounge, where all the activities, on offer are displayed. Since the last inspection, the home has started to record the activities participated in and who by in a diary; however further improvements are required to this, as this should be documented on the individual files. Some personal hobbies and interests were recorded on files, but were not written into care plans and this requires further development. Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 13 Residents can go outside of the home with family and friends and one resident said “My daughter comes and takes me out”. Another resident stated that she had “a number of visitors who come to the home and they are made to feel very welcome”. One resident stated that she “would like to go out more often” and this was discussed with the manager at the time of the inspection. Staff take the residents out to the local shops to purchase items. Visitors can come to the home at anytime. Breakfast was being served on arrival at the home and staff were observed to be offering the residents a choice. Residents were observed to be chatting amongst themselves. Soft music was playing in the background. Menus are on a four-week cycle and amendments have been made to this, to include an alternative to fish dishes on Fridays. The daily food record has been improved to allow for the documentation of suppers and the choices for supper have been incorporated onto the menu for residents to view. One resident said, “There is a choice each day and today was braised steak, Cornish pasty or salad” Alexandra House DS0000004516.V265246.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, 18 The complaints procedure is comprehensive and accessible to the residents and their visitors should they need to make a complaint. The home has systems in place to protect residents from abuse. EVIDENCE: The home had a comprehensive complaints procedure and this was on display in the lounge. Improvements have been made since the last inspection as the home now has a complaints file, however it is recommended that this be altered to include a “grumbles log” as there were three comments on the file, which were recorded as complaints, but were requests from residents, all of which had been dealt with satisfactorily and the outcome recorded. The manager must decide what constitutes a complaint or a grumble. The home has not received any formal complaints since the last inspection and CSCI have not received any complaints pertaining to Alexandra House. The home has also received Thank you cards and letters, which are kept in a folder. One resident stated “I would talk to the manager if I had a problem and she would sort it out if she could, if she couldn’t she would recommend a solution” The adult protection policy has been amended since the last inspection and is in line with the multi agency guidelines. Staff training for adult abuse and challenging behaviour has been booked for the New Year. Alexandra House DS0000004516.V265246.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, 21, 23, 24, 25, 26 Alexandra House provides a homely, comfortable and safe environment in which service users are relaxed and secure. EVIDENCE: At the last inspection some areas of the home where noted to have an offensive odour and this appears to have been resolved with the exception of one identified bedroom. The manager has involved community nurses in this residents care to try and minimise the problem of incontinence, however the manager must address the odour of the room. Staff had put talcum powder on the mattress after cleaning it and it is required that this practice ceases due to potential infection control risk and damage to the air mattress. Air fresheners have been purchased which are programmed to release the freshener every fifteen minutes and these have been installed into the corridor areas of the home. Adequate assisted bathing facilities were available, however lack of storage space meant that commodes and hoists were being stored in one of the bathrooms behind shower curtains. The manager stated that the residents did Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 16 not use this shower room. Toilets were found to be clean and handrails and raised toilet seats are available as required, as were hygienic hand washing facilities. Improvements have been made in relation to infection control concerns, in relation to the sluice facilities at the home, since the last inspection. Recommendations made by the health protection unit have been implemented to minimise the risk of cross infection and potential health and safety risks posed. This included fitting of shelves and wall mounted clips, pedal bins and the use of disposable wipes for cleaning. The current macerator machines are acceptable for the home until they require replacement. Some bedrooms were reviewed and these were personalised with resident’s own possessions to ensure that their surroundings are as comfortable as possible. One resident stated, “My bedroom is very good” Alexandra House DS0000004516.V265246.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, 30 The home has maintained adequate staffing levels, and staff undertake training to improve their level of knowledge of caring for older people. EVIDENCE: Staffing levels have been maintained at Alexandra House, with only one care assistant leaving since the last inspection. There have been no new recruits to the home since the last inspection, and one carer is due to start once all the necessary checks are completed and in place. Staffing rotas were not reviewed on this occasion, however seven members of staff were on duty. On the day of the inspection an extra staff member from an agency was on duty as there was fire training for some of the permanent staff. The Registered Manager provides on call support to the person in charge of the shift, however this is not recorded on the staffing rotas. The arrangements for the on call support need to be reviewed to ensure that the Registered Manager has some free time when she is not on call. Comments from residents included ”Staff are splendid and know what I need” ”Staff are excellent and most of them have been here for years” ”Staff are very good” Staff recruitment procedures and files were not reviewed on this occasion, however the recruitment procedure was found to be robust at the last inspection. Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 18 Since the last inspection staff have received training in Food Hygiene awareness, Health and Safety, Parkinsons disease awareness, COSHH training, Care of the terminally ill and safe handling of medicines. The manager was pleased that the training budget has been increased recently and further training is booked for Dementia, challenging behaviour and abuse training. Alexandra House DS0000004516.V265246.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): 31, 33, 38 The Registered Manager ensures that a good standard of service is provided at the home. Whilst the home has mechanisms for feedback from service users, the quality assurance system needs to be further developed to ensure a consistent improving service. EVIDENCE: The Registered Manager has had much experience in caring for older people and has the appropriate qualification to perform well within her management role. One resident said, “This home is extremely well run and it’s very efficient” The manager has completed a Fire Marshall course and completed an accredited safe handling of medicines course. Regulation 26 reports are sent to CSCI after the Director has made visits to Alexandra House, and this ensure a high standard of service is provided at the home. A formal quality assurance system has been purchased by the home Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 20 and is being implemented. A new questionnaire has been devised and this will be sent out to residents and families of those who are unable to complete for themselves. Residents meetings are held in the form of coffee mornings, however no minutes of meetings were available to evidence this. Meetings must take place and minutes recorded to ensure that residents and their families are given the opportunity to discuss and share any ideas or concerns about the home in an open and inclusive atmosphere. Some staff were receiving fire training on the day of the inspection and there was evidence that fire drills have taken place, to ensure that staff know how to respond in the event of a fire. Means of escape, safety signs and fire alarm detection systems are checked weekly. Emergency lighting is checked monthly. Both the Registered Manager and the Deputy Manager have completed training courses for Fire Marshall’s. Accident records were fully detailed and the Registered Manager reviews all reports. Some auditing has taken place however this requires further development to ensure that any trends are picked up and acted upon. A fire risk assessment had been undertaken, however this provided little information and did not identify specific risks. This requires further development to identify potential hazards around the home and it is recommended that the Registered Manager contacts the Fire Officer for further advice. A premises risk assessment had been undertaken, however this also provided limited information. Some areas had been identified in the report as requiring attention, and the manager is to forward outcomes of these requirements to the CSCI. This report had been undertaken in June but the Manager had not seen this report and it is essential that the site maintenance staff ensure the manager is aware of any reports pertaining to the home. Alexandra House DS0000004516.V265246.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 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 2 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X X X X 2 Alexandra House DS0000004516.V265246.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. 2. Standard OP2 OP7 Regulation 17 (2) 13 (4) a,b,c (2) Requirement Timescale for action 11/01/06 All residents must have a signed statement of terms and conditions in place on their files. Personal risk assessments of 01/02/06 residents must contain sufficient detail of the actions to remove or reduce the risks identified. (Previous time scale of 31/10/04, 06/04/05 and 31/08/05, not met) The care planning system must be further developed including: Care plans must detail the action to be taken by care staff to ensure that all aspects of the personal, health and social care needs of residents are met. (Previous timescale of 31/08/05 not met) Care plans must be written in respect of aggressive or challenging behaviour. Information obtained on the pre admission assessment must be incorporated into care plans. 3. OP7 15(1)(2) 01/02/06 Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 23 4. 5. OP7 OP9 17 13(2) 17(1)a Sch(3)I Tippex correction fluid must not be used on documentation. Improvements are required in respect of the management of medication including: Prescription ointments must be signed for following administration. Regular medication audits must be undertaken, and written evidence of this maintained. The actual amount of medication administered for variable dosage medications must be recorded on the medication charts. (Previous timescale of 31/07/05 not met) Activity care plans must be written and a log of social activities must be recorded in individual files. The odour in one identified bedroom must be addressed. Talcum powder must not be used on mattresses following cleaning, as is an infection control risk, and could damage the equipment. Residents meetings must take place to ensure that residents and their families are given the opportunity to discuss and share any ideas or concerns about the home in an open and inclusive atmosphere. Minutes from meetings must be available. (Previous timescale of 01/09/05 not met) A formal quality assurance system must be implemented at the home and quality surveys must demonstrate how the quality of care has been DS0000004516.V265246.R01.S.doc 23/12/05 06/01/06 6. OP12 15(1) 16(2m,n) 13 (3) 16 (2)j,k 16 (2)j,k 01/02/06 7. 8. OP26 OP26 30/12/05 23/12/05 9. OP32 24 31/01/06 12(2) 10. OP33 24 03/03/06 Alexandra House Version 5.0 Page 24 reviewed and improved as a result of the survey being carried out. A report based on the findings of these surveys must be produced and accessible to all interested parties. (Time scale of 06/06/05 & 08/11/05 not met, however a quality assurance system has been purchased and is being implemented) The premises risk assessment must be reviewed by the manager and evidence sent to CSCI that: *An asbestos survey has been completed. *A risk assessment of hot and cold water systems is completed. *The home is complying with the new hazardous waste regulations. Specific risks throughout the internal and external environment must have a written risk assessment. Fire risk assessments require 03/02/06 further improvements to identify specific risks and potential hazards around the home. The Registered Manager must 13/01/05 audit all accidents involving residents living at the home. (Previous timescale of 31/07/05 not met) 11. OP38 13 (4) 03/02/06 12. OP38 23 (4) 13. OP38 13(4) Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is recommended that identity photographs be kept alongside MAR charts. It is recommended that a copy of prescriptions is kept alongside the MAR chart. It is recommended that a “Grumbles log” is commenced alongside the complaints log. Wheelchairs and hoist should not be stored in bathrooms and an alternative storage facility for these should be sought. Detail of the arrangements for on call support for the person in charge of the shift should be recorded on the staffing rotas. It is recommended that the Manager liaise with the fire officer for information regarding risk assessments. 2. 3. 4. 5. OP16 OP21 OP27 OP38 Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Alexandra House DS0000004516.V265246.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!