Inspection on 06/03/06 for Andrew Smith House

This inspection was carried out on 6th March 2006.

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

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

Other inspections for this house

Andrew Smith House 09/10/07

Andrew Smith House 20/02/07

Andrew Smith House 19/07/05

Andrew Smith House 24/10/04

Andrew Smith House 19/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Andrew Smith House Marsden Hall Road North Nelson Lancashire BB8 8JN Lead Inspector Mrs Marie Matthews Unannounced Inspection 09:30 6 March 2006 th X10029.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 Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 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 and Care Homes for Adults 18 – 65*. 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. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Andrew Smith House Address Marsden Hall Road North Nelson Lancashire BB8 8JN 01282 613585 01282 611630 julie.gaskell@btconnect.com 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) Stocks Hall Care Homes Limited Mrs Julie Elizabeth Gaskell Care Home 60 Category(ies) of Dementia (12), Dementia - over 65 years of age registration, with number (12), Old age, not falling within any other of places category (40), Physical disability (20) Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 60 service users to include: A maximum of 40 service users in the category of OP (older people) A maximum of 20 service users in the category of PD (physical disability under 65 years of age). A maximum of 12 service users in the category of either DE (Dementia) or DE(E) (Dementia under 65 years of age) Date of last inspection 19th July 2005 Brief Description of the Service: Andrew Smith Care Home in Nelson is part of a group of homes owned by Stocks Hall Care Homes. It is a two-storey property with a lift to all floors and wheelchair access to all parts of the home. The home has recently extended and upgraded the facilities and is registered to provide both nursing and personal care for up to sixty people in four separate units. The home provides a twelve-bed dementia unit, eight-bed younger disabled unit, seven-bed rehabilitation unit and thirty-three bedded unit for older people. The home is located in Nelson across from a school and is close to the local park, community centre and shops. There is a bus service nearby and the home has a small car park. The outside of the home has patios and grassed areas which are accessible to the residents and their visitors. The home has a number of lounges and dining areas on both floors and there is a smoking lounge available on the second floor. There is a small conservatory at the side of the home and the entrance area is also a popular place for sitting and meeting visitors. The home offers single rooms some of which are en-suite; throughout the home are toilets, bathrooms and showers all of which have adaptations to assist the service users. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted at Andrew Smith House on 6th March 2006. The inspection involved looking at records, talking to management, staff, nine residents and four visitors, a tour of the home and generally looking at what was happening in the home. This inspection looked at things that should have been done since the last inspection and a number of areas that affect resident’s lives. Since the last inspection the home had extended its facilities to provide a unit for younger people and a unit for people with dementia. There were fifty-nine people living in the home on the day of the visit. To obtain an overall view of the home the report of 19th July 2005 should also be read. What the service does well: Residents and prospective residents were given information about the services the home provided. This helped them to make decisions about whether the home could meet their needs and look after them properly. The home always completed assessment visits before people were admitted to be sure they had the skills and expertise to meet their needs. The home made sure that people were able to be as independent as possible by providing specialist aids and equipment around the home. Residents said they were able to make choices and decisions about many aspects of their lives. Various suitable activities were taking place in different areas of the home and residents were able to choose which activities to ‘join in’ with. The home had use of specialised transport for planned group and one to one outings. Information about local activities and entertainments was available. Visitors felt ‘welcomed’ into the home and could visit in any area of the home. The home had small kitchen areas on each floor and residents and visitors were able to make a drink if needed. Residents were complimentary about the food and said they were always given a choice. The menu offered varied and nutritious meals. Residents on the younger adults and rehabilitation units were able to use the unit kitchens to prepare simple meals. The home had a good complaints system and people were aware of whom to talk to if they were unhappy and felt their views would be listened to and acted upon. Staff had access to clear policies and procedures about how to recognise and respond to adult abuse. Training was included as part of the initial induction for new staff; this made sure residents were protected from harm. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 6 Rooms were bright, airy and comfortably furnished and personal items had been brought in to add to the ‘homely’ feel of the home. Residents were happy with their rooms. Comments from residents included ‘my room is very comfortable’, ‘my room is a good size and nicely decorated’ and one resident said ‘ I couldn’t wish for better’. Residents and visitors made positive comments about the décor of the home. The home had a thorough recruitment procedure to make sure staff were suitable to work at the home and that residents were protected. Training records showed staff had been provided with appropriate training and supervision to assist them to meet the needs of the residents in their care. The home was good at asking people if they were meeting their needs. Surveys had been sent out to residents, visitors and other people such as GPs, physiotherapists and occupational therapists. Health and safety records had generally been maintained and safe systems protected residents, staff and visitors to the home. What has improved since the last inspection? What they could do better: All residents had a plan of care. The plans were clear and organised but did not always detail the action to be taken by staff to make sure resident’s were looked after. There was little evidence that residents or their relatives were involved in decisions about changes to their care plan. Medication policies and procedures needed further additions to make sure staff had the correct guidance to follow and this would keep residents safe. The home needed to consider involving residents in the interviewing and selection of new staff; this would make sure that residents were happy with the choice of staff. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 7 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. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) 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, 3 and 6 (older people) and 2 (adults 18-65). Residents and prospective residents were given information about the services the home provided. This helped them to make decisions about whether the home could meet their needs. The home always completed detailed assessments and confirmed whether they were able to meet resident’s needs prior to admission. EVIDENCE: The statement of purpose and service user guide had been reviewed and provided people with detailed information about the services offered by the home. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 10 Two care files were looked at. The home had completed detailed assessments to make sure they were able to look after people properly before they were admitted. Care plans included information obtained from assessments. The home had a separate unit that provided care for short stay residents who required rehabilitation before returning home. This unit had separate facilities. Staff that had been appropriately trained and were supported by qualified physiotherapists and occupational therapists gave care. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 9 (older people) and 6, 9, 16, 18, 19 and 20 (adults 18-65) The care planning system was clear and organised but did not always detail the action to be taken to meet resident’s needs. Residents and relatives were not involved in the development and review of their care plan. The medication policies and procedures did not provide staff with clear guidance on all aspects of medication management and this could put residents at risk. EVIDENCE: Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 12 Two resident care plans were looked at. The plans included information from the initial assessment. The plans were clear, organised and generally detailed the action to be taken by staff to make sure resident’s needs were met. Preferences had been recorded and residents said support was given flexibly. Various assessments had been included but information about the appropriate action to be taken when a risk had been identified had not always been included. The care plans had been reviewed but there was little evidence that residents or their relatives had been involved in the development, review and update of the care plan. Specialist and healthcare support was given as needed. Aids and adaptations had been provided around the home to maximise people’s independence. Residents said they were able to come and go as they wished and any restrictions had been detailed in the care plan. Medication policies and procedures needed further additions to ensure staff had the correct guidance. Records were generally clear although a number of gaps were noted on the medication administration record and appropriate coding had not been used. Oxygen cylinders needed to be stored safely and a record of room temperatures needed to be maintained in areas where medicines were stored. Storage areas were clean and tidy. Medications were stored securely. Resident’s consent to medication should be obtained and recorded in the care plan (adults 18-65). Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 (older people) and 12, 13, 15 and 17 (adults 18-65). The home provided appropriate and varied activities that met resident’s needs and expectations. The home provided residents with a varied, wholesome and nutritious diet. EVIDENCE: Appropriate activities were taking place in various areas of the home. One resident said activities were provided but she preferred not to ‘join in’. Residents said they were given choices in many aspects of their day. Outings had been arranged and the home had use of a minibus or cars. Residents were Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 14 able to involve themselves in the local community and information about local activities and entertainments was available on the notice board. Visitors to the home said they were made to feel welcome and kept up to date with any changes to care. All units were provided with meals from the main kitchen. Residents were complimentary about the food and said they were always given a choice menu. Residents on the younger adults unit had use of their own kitchen area; one resident said they had been baking. Nutritional assessments were included as part of the care planning. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 (older people) and 22 and 23 (adults 18-65) The home provided staff with clear guidance and training to ensure residents were protected from abuse, neglect and self-harm. The home had a good complaints system with some evidence that people felt their views were listened to and acted upon. EVIDENCE: The home had clear policies and procedures about how to recognise and respond to adult abuse. Training for new staff was included as part of the initial induction. Residents and their visitors had been given information and were aware of whom to complain to if they were unhappy with their care. Clear records had been maintained and any concerns had been responded to promptly and appropriately. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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, 26 (older people) and 24 and 30 (adults 18-65) The standard of the environment within this home was good and provided residents with a clean, homely, safe, comfortable and attractive place to live. EVIDENCE: The home was clean, safe, accessible and well maintained. Resident’s rooms were bright, airy and comfortably furnished and personal items had been brought in to add to the ‘homely’ feel of the home. All resident’s rooms had a lockable storage space and a lock to the room door. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 17 Residents were happy with their rooms. Comments from residents included ‘my room is very comfortable’, ‘my room is a good size and nicely decorated’ and one resident said ‘ I couldn’t wish for better’. A number of bedrooms and communal areas had been redecorated and refurbished to a high standard. Residents and visitors made positive comments about the décor of the home. The young disabled unit had been designed to provide access for wheelchair users. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 (older people) and 32, 34 and 35 (adults 18-65) The residents were protected by the home’s thorough recruitment procedures. The home gave staff appropriate training and supervision to ensure they were able to meet the needs of the people in their care. EVIDENCE: Sufficient staff were provided on all units and staffing levels had been kept under review. New staff had started and the units were fully staffed. This meant the home did not have to cover as many shifts with agency staff and could provide residents with care given by staff that were aware of their needs. Training records showed staff had been provided with appropriate training and supervision to assist them to meet the needs of the residents in their care. The home was committed to training staff to NVQ level 2 and 3. Two staff files were looked at. Both files contained the required employment checks and showed that residents were protected by a thorough recruitment Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 19 procedure. Consideration must be given to including residents in the interview and selection of new staff. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 (older people) and 37, 39 and 42 (adults 18-65) The home regularly reviewed its performance and sought the views of residents, staff and visitors to the home. Health and safety records had generally been maintained and safe systems protected residents, staff and visitors to the home. EVIDENCE: Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 21 Clear accounting and financial records were maintained; these records were regularly audited to ensure residents best interests were protected. Residents and visitors said they attended regular meetings and had completed surveys about whether the home was meeting their needs. The results of the recent surveys had been made available. A survey was sent to people such as GPs, physiotherapists and occupational therapists; the results were held on file. Health and safety records had generally been maintained and safe systems protected residents, staff and visitors to the home. It was noted that the temperatures of hot water outlets had not been tested throughout the home; this was discussed with the registered manager. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 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 3 2 X 3 3 4 X 5 X 6 3 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 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 3 26 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 3 34 X 35 3 36 X 37 X 38 2 Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 23 YES 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 OP7YA6 Regulation 14 Requirement Care plans must cover all aspects of their health, personal and social needs and indicate action to be taken by staff to meet these needs. The resident must hold the plan unless there are documented reasons not to do so. Residents and their family, friends or advocate must be involved in the development of the care plan and there must be evidence to support this. The registered person must ensure administration of all medications is recorded on the Medication Administration Record charts and appropriate coding is used for any omissions. Medication policies and procedures must be reviewed to include all aspects of medication management and to reflect current practice. The temperatures of medication storage areas must be monitored regularly. Timescale for action 24/04/06 2. OP7YA6 15 24/04/06 3. OP9YA20 13 24/04/06 4. OP9YA20 13 24/04/06 5. OP9YA20 13 24/04/06 Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 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 OP9YA20 YA34 OP31YA37 OP38YA42 Good Practice Recommendations Oxygen cylinders should be stored on a trolley or link chained. Residents should be involved in the interview and selection process The registered manager should have an appropriate management qualification. All hot water temperature outlets, accessible to residents, should be tested regularly. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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. Andrew Smith House DS0000022506.V282693.R01.S.doc Version 5.1 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. 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. 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