Inspection on 24/07/07 for Amberley

This inspection was carried out on 24th July 2007.

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

Amberley 18/06/09

Amberley 01/07/08

Amberley 14/08/06

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 Amberley 481-483 Stourbridge Rd Brierley Hill West Midlands DY5 1LB Lead Inspector Ms Linda Elsaleh Unannounced Inspection 10:30 24 & 25th July 2007 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 Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amberley Address 481-483 Stourbridge Rd Brierley Hill West Midlands DY5 1LB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01384 482365 Merron Care Ltd vacant post Care Home 25 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (14), Physical disability (5) of places Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2007 Brief Description of the Service: Amberley is a purpose built private residential care home, registered to provide care for 25 older people. The home is situated on the main Stourbridge Road between Dudley and Brierley Hill. It is on the main bus route to local towns and there are many local amenities close by. There is off road car parking to the front and rear of the premises. Access to the home is through a small garden and patio area to the rear of the property. The premises have three storeys, with Service Users accommodation on all floors. A passenger lift services all floors. The accommodation comprises; communal lounge and dining rooms and 21 single and 2 double bedrooms. Toilet and bathing facilities are located on each floor and the main kitchen and laundry area are located on the ground floor. The weekly fee for this service ranges from £338.00 to £373.00. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 24th & 25th July 2007. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Adults and report on the progress made to address the requirements made at the previous inspection. The inspector’s findings are based on the information received by the Commission for Social Care Inspection (CSCI) and examination of relevant records and documents kept at the home. The files of three service users and three staff were examined in detail. Interviews were conducted with the manager, staff and service users. Comments were received from relatives who were visiting the home. The manager has made progress in addressing the requirements and recommendations made at the previous inspection. Generally comments from service users were complimentary about the service afforded them. One service user said “I’m happy to be here”. Positive comments were also received from visitors about the care provided to their relatives. What the service does well: What has improved since the last inspection? The manager has carried out a review of care practices. Formal arrangements have been made for information to be exchanged between shifts. Service users are provided with a wider range of activities. The home is making further improvements to meeting service users social needs. A programme for the redecoration and refurbishment of the home has been identified. However, a timescale for its implementation has yet to be produced. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 6 The manager has produced a quality assurance system and a development plan for improving the service. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is good. Prospective service users receive information about the service and are invited to visit, and move in on a trial basis, to enable them to make an informed choice about where to live. The needs of prospective service users are assessed and the home provides written confirmation that it is able to meet their needs. Each service user has been provided with a Contract/Statement of Conditions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users and relatives who commented stated they were provided with a copy of the home’s Statement of Purpose and additional information about the service. They also spoke positively about arrangements made for them to visit the home prior to moving in. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 9 The contracts/statements of terms and conditions are available on service users files. However, some service users do not have contracts with the current provider. The files show copies of Care Management Assessments are obtained from the referring agencies. The home also undertakes its own assessment for which individual care plans are produced. The home has confirmed in writing that they are able to meet the needs of prospective service users. A copy of the home’s Policy for Meeting Service Users Needs is also kept on the files. This document is not dated. The manager is advised to review this to ensure the process remains appropriate for the service being provided. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is adequate. Service users would benefit from having all their identified needs detailed in their individual plan of care. The home operates a good system for dealing with service users medication. In general service users personal preferences are observed, they are treated with respect and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager for the current provider has carried out an internal audit of service users care plans and risk assessments. However, in some instances an individual care and/or risk assessment has not been produced in accordance with the findings of the assessment tool used by the home. The files show incidents were the need for monitoring dietary in-take, providing assistance with mobilising and managing challenging behaviour have Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 11 been identified a care plan and/or risk assessment has not been produced. Staff keep a record of the monthly reviews carried out on service users care plans. The manager stated she monitors these records and regularly discusses the review with staff and service users. There is no record of these discussions or evidence of the manager’s monitoring of the review records. A record is kept of all health care appointments and regular consultations take place with health care specialists. Assessment reports produced by healthcare specialists are also available. A report produced by the continence advisor for one service user recommended support be provided to encourage and assist the service user in managing her/his incontinence. A plan detailing how this support is to be provided has yet to be produced by the home. Senior members of staff are responsible for ordering, administering and returning unused medication. The records show ASET training in the safe handling and administration of medication has been provided for senior staff. A record of prescribed medication is kept on the service users files. A random selection of Medication Administration Records were examined and found to be appropriately maintained. The home has obtained confirmation from general practitioners (GPs) for the use of homely remedies. The manager stated, in such cases, discussions are held with the GP before any homely remedies are administered. The manager is advised to review its policy and procedures for the safe handling and administration of medication to ensure all aspects are covered, including the handling of keys. Service users are able to consult with healthcare professionals in private and receive visitors in the privacy of their own bedrooms. The home has a visiting hairdresser who is popular with the service users. Staff discussed how they protect service users rights to dignity and privacy. For example, using the service user’s preferred term of address and knocking doors before entering bedrooms. In general, the observations made by the inspector demonstrated this was the case. The toiletries kept in the communal bathrooms were discussed with the manager. These should be removed and kept in service users own bedrooms. During this visit the inspector spoke with a recently bereaved relative. S/he praised the home for the care provided and the support offered to her/his family. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. Service users are provided with suitable activities and are able to follow preferred routines and interests. They are able to maintain contact with relatives and friends. The home provides meals that are wholesome, appealing and meet service users individual dietary needs and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are encouraged to participate in various activities such as bingo, puzzles, craft and board games. They also enjoy sing-a-long sessions and a little dance around the lounge. A variety of books and games are available. Staff was observed encouraging service users to participate in activities. There is an activity programme in reception. However, staff stated this is more a guide and not always followed, as service users often make their own make decisions about what they would like to do. Service users are supported to assist with light tasks in the home, where appropriate, such as helping in the dining room or to hang out the washing. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 13 Services users who expressed an opinion commented positively on the activities provided by the home, as did their relatives. The manager and senior staff discussed the work they are doing to expand the information they have about service users lives and interests. One relative confirmed recent discussions had taken place with staff about her/his relative’s interests. The manager stated this would enable more meaningful individual and group activity programmes to be produced. Consideration is also being given to employing an activity co-ordinator. Visitors are welcome to the home. Several visitors, health & social care professionals, as well as relatives and friends were seen visiting service users throughout this inspection. All visitors are requested to complete the Visitors Book on their arrival and when leaving for safety reasons. Service users commented positively about the food provided. The inspector joined the service users for their main meal in the dining room, while other service users were served their meal in the lounge. One service user chose to have her/his meal in their bedroom. The menu for the day is displayed in the dining room. Alternatives meals are provided on request. There is a list of dietary needs and personal likes and dislikes in the kitchen. Care staff have attended training in basic food hygiene. They were attentive to service users needs throughout the meal. A cook is on duty each day to prepare meals and carry out other associated duties. However, gaps in recording for food, fridge, freezer temperatures and cleaning schedules were brought to the manager’s attention. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 Quality in this outcome area is adequate. Service users, their relatives and friends are confident in the home’s systems for dealing with concerns and/or complaints. Service users rights are protected by the home’s systems. However, robust procedures for managing personal allowance, adult protection and training for staff need to be reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recently reviewed its complaints procedure. A copy is on display in reception with a book for recording any comments & complaints. Previous complaints received about the home have been dealt with. No complaints have been made to the Commission for Social Care Inspection (CSCI) during the last 6 months. The current manager records any issues of concern raised with her or her staff. Comments received from service users and visitors were positive. They stated they are confident that the manager will satisfactorily address any suggestions or queries they raise. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 15 The home manages the personal allowances for the majority of service users. There is no policy or procedure for this and details are not included in the service users files. However, the records kept by the manager are well organised. A copy of the Local Authority’s procedures for Safeguarding Vulnerable Adults is available in the home. The home’s policy and procedure needs to be revised to ensure it is compatible with the local authority’s procedures. Arrangements have still to be made for some staff to attend training in adult protection issues. As previously mentioned, there are times when some service users present challenging behaviour. Procedures in managing such behaviours need to be produced and suitable training provided for staff. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23, 24 & 26 Quality in this outcome area is adequate. Service users live in a safe environment. The comfort for service users would be enhanced by the timely completion of the home’s redecorating and refurbishment programme. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a purpose built, three-storey building with off-road parking. There is a passenger lift for accessing the first and second floors. The garden is well kept and there is a patio area where service users can sit during fine weather. The manager spoke about some ideas she has for the garden, such as providing raised flowerbeds. The home has two lounges. The main lounge is on the ground floor and is favoured by service users. The smaller lounge is not used as often. The Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 17 manager stated it is usually used for meetings and, sometimes, by service users when receiving visitors. It is appropriately furnished, however, miscellaneous items are being stored here. Hence, making it a less attractive room for service users and visitors. The main kitchen is appropriately equipped and has the necessary appliances. Arrangements are made for these to be regular serviced and maintained. The home has a more domestic style kitchen on the first floor. The inspector was informed this facility is for visitors or service users, who wish to and are able, to make drinks and light snacks. At present this is not possible due to appliances, such as a washing machine, being stored here while waiting to be disposed of. The mobile hoist is also being stored in this room. Bathing and toilet facilities are located on all floors and suitable bathing aids are provided. These areas are in need of re-decoration and/or refurbishment. The small shower facility on the second floor is not working and is being used for storage. The laundry and sluice facilities are located on the ground floor. Information about hygiene and infection control and control of substances hazardous to health (COSHH) are available in these areas. The home employs two domestic assistants to carry out general cleaning duties. Arrangements are being made for all staff to attend training in infection control. The home has a small number of double bedrooms. Service users have personalised their bedrooms with their own possessions and small items of furniture. The manager has identified bedrooms for re-decoration and is discussing the availability of the handy person with the provider. Attention needs to be given to the damage caused by the closure devices fitted to bedroom doors. Commodes are provided in bedrooms were requested. Some of these are looking worn and should be replaced. Carpets in some bedrooms have been replaced with vinyl flooring which is easier to clean. A record of this decision and the service user’s agreement is not kept on their files. A slight malodour was noted in two or three bedrooms. The manager stated new equipment and cleaning products had been purchased to address this. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. Service users are supported and protected by the home’s recruitment practices. Staff are provided in sufficient numbers and with the appropriate skills to care for the service users. The home provides training for staff to enable them to carry out their duties. Service users will benefit further from a planned programme of training being produced for staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users needs are met by sufficient numbers of experienced staff. At the time of this visit four care staff where on duty during the daytime hours. This includes a minimum of one senior care officer. The manager is not included in these hours. A domestic assistant and cook are on duty to carry out ancillary duties. Two staff are on duty to provide care during night-time hours. Changes made to staff or staff hours are not always clearly recorded on the rota. The importance of keeping accurate records was discussed with the manager. Since the last inspection there has been significant changes in the staff team. The manager and staff commented that this had led to positive changes in care Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 19 practices and team development. Staff interviewed demonstrated a clear understanding of their role and responsibilities and the roles of other members of the team. The home has policies and procedures for the recruitment and retention of staff. The random selection of staff records examined demonstrated appropriate procedures are carried out and relevant checks undertaken. Contracts of Employment and Codes of Practice have been issued to staff. Induction training is provided to new staff. The records for the areas of induction covered were incomplete. The manager is advised to review the programme implemented by the home and ensure appropriate records are kept. Information provided by the home shows 40 of the current staff team hold a National Vocational Qualification Level 2 or above. Other staff are currently working towards this qualification. A record is kept of training completed by staff. The random sample of records examined show a comprehensive training programme has been attended by a senior member of staff. The records for care assistants show various training courses have yet to be completed, such as Fire Safety, Manual Handling, Infection Control and Safeguarding Vulnerable Adults, Caring for People with Dementia & Managing Challenging Behaviour. The manager stated she is producing a suitable programme to ensure training is provided to new staff in a timely manner. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. Service users live in a home that is managed by a competent person who provides the staff with positive leadership. The health, safety and welfare of service users are safeguarded by systems for monitoring and addressing health & safety issues. Service users best interests are promoted through staff practices. This judgement has been made using available evidence including a visit to this service. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 21 EVIDENCE: The current manager is experienced in working at a senior level with older adults. She is due to attend an interview with the Commission for Social Care Inspection (CSCI) as part of the process for registration as manager of Amberley. Positive comments were received from service users, staff and visitors about the way in which the home is managed. The home has produced a quality assurance system for monitoring its performance and developing the service. This includes regular consultation with service users and staff. Relatives and other stakeholders are requested periodically to complete surveys. Action plans have been produced based on the evaluation of the information received. The manager is advised to develop a system for feeding back to service users and stakeholders the findings from consultations and surveys and the home’s plans for developing the service. As previously stated the home does not have a procedure for managing service users personal allowances. However, systems are in place to ensure money is available when required/requested and good records are maintained. The manager has recently implemented a system for the formal supervision of staff. The supervision records do not contain much detail. A senior member of staff described her new role as mentor. The manager stated this had been introduced to provide guidance and support to a newly promoted member of staff. The manager is advised to review the home’s policy for supervision to ensure all aspects are covered, including the role of mentor and recording. Records are available for the maintenance and service of appliances and equipment. The maintenance of fire safety systems and appliances was carried out in April this year. As previously reported, health & safety information is accessible to staff. Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 22 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 2 2 3 2 3 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement A care plan must include all identified elements of the service user’s needs and, were appropriate, risk assessments produced. Records must be kept of arrangements made with service users and/or their representative for the home to manage personal allowances on their behalf. All staff must receive training in Safeguarding Vulnerable Adults. The manager must arrange for worn commodes to be replaced. The manager must make arrangements for items stored in communal rooms to be removed. The manager must remove the items stored in the upstairs shower and arrange for it to be restored to working order. Timescale for action 19/10/07 2. OP17 15 19/10/07 3. 4. 5. 6. OP18 OP19 OP20 OP21 12 23 23 23 19/10/07 19/10/07 19/10/07 19/10/07 Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 24 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. Refer to Standard OP2 OP4 OP7 OP9 Good Practice Recommendations The manager should arrange for new contracts/statement of terms and conditions to be agreed between the current provider and service users. The Policy for Meeting Service Users Needs should be reviewed to enable service users to be confident their needs will continue to be appropriately met. The manager should ensure records are kept of her monitoring of staff’s review of care plans and discussions held with service users. The manager should review the home’s policy and procedure for the safe handling and administration of medication to ensure all aspects are covered, including instructions for the handling of keys. The manager should ensure appropriate records are kept of food, fridge, and freezer temperatures and cleaning carried out be catering staff. A policy and procedure should be produced for the home’s management of service users allowances. The home’s procedures for Safeguarding Vulnerable Adults should be reviewed to ensure compatibility with the local authority’s procedures. The manager should arrange for attention to be given to the prevention of continual damage being caused to bedroom walls by door closures. The manager should ensure records are kept of discussions held with service users about the replacement of floor coverings in her/his bedroom. The manager should ensure accurate records are kept of hours worked by staff. The manager is should review the home’s policy for supervision. This should include the role of the mentor. 5. 6. 7. 8. 9. 10. 11. OP15 OP17 OP18 OP19 OP23 OP27 OP36 Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Amberley DS0000067358.V332729.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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