Inspection on 29/12/08 for Avalon

This inspection was carried out on 29th December 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avalon 29/12/06

Avalon 28/02/06

Avalon 31/10/05

Avalon 21/03/05

Avalon 30/11/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/06/2011.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Avalon Longhouse Road Chadwell St Mary Grays Essex RM16 4QP The quality rating for this care home is: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Pauline Marshall Date: 2 9 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Inspection report CSCI Page 2 of 31 Care Homes for Adults (18-65 years) Audience Further copies from Copyright General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Avalon Longhouse Road Chadwell St Mary Grays Essex RM16 4QP 01375841402 F/P01375841402 avalon.nursing@familymosaic.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Family Mosaic care home 8 Number of places (if applicable): Under 65 Over 65 8 0 learning disability Additional conditions: Excluding any person who is liable to be detained under the provisions of the Mental Health Act 1983 Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 31 A bit about the care home Avalon provides nursing care for eight adults with learning disabilities. The building is two bungalows joined together to make one large home. The property is in a residential area of Grays, it is near to the local shops and bus routes and trains to London and Southend are about a mile away from the home. There is a qualified nurse in the home at all times and they have experience and qualifications in learning disabilities. Each person living at the home has a key worker and a named nurse. A copy of the homes Statement of Purpose and Service User Guide is given to anyone wishing to live in the home. The current fees are £1115.00 per week and people pay contributions of between £62.35 and £102.90 per week depending on their income. Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 31 How we did our inspection: This is what the inspector did when they were at the care home We were at the home for three hours and forty-five minutes. We talked with the manager and staff and we looked at a random sample of files (including those of staff and people living in the home) and some of the records that the home is required to keep. ANNUAL QUALITY ASSURANCE ASSESSMENT (AQAA) We looked at all of the key standards and walked around the home. The manager completed her annual quality assurance assessment (AQAA) and information from this has been reflected right through this report. The AQAA is a form required by law for the manager or provider to carry out a self-assessment of how well the outcomes of people using their services are being met. We sent surveys to the manager to distribute to eight people who live at the home, eight of their relatives, three health Care Homes for Adults (18-65 years) Page 7 of 31 WHAT YOU THINK ABOUT THE HOME? and social care professionals and eight care staff. At the time of writing this report one survey was returned from a person living in the home; five surveys were completed by staff, however the surveys returned were meant for relatives of people living in the home so they could not be accurately completed by the staff. Where possible we have included any comments received in the surveys in the main sections of this report. What the care home does well Avalon makes sure that they can meet the needs of people before they move in and gives people good up to date information about the service that includes pictures of the home. The support plans are well written and include lots of information to help staff to provide the right level of support that people need. Avalon offers people a range of activities that includes aromatherapy and regular visits from the music man. People have regular opportunities to visit local shops, pubs and restaurants. There is a good healthy balanced diet on offer and an alternative menu gives people plenty of Care Homes for Adults (18-65 years) Page 8 of 31 choice if they dont want the meal offered in the main menu. The manager is committed to providing people with a high quality of care and she has a positive attitude and gets on well with people living in the home and the staff team. What has got better from the last inspection The training programme is better and the manager now keeps a list of the training that staff have had and the training that they will need in the future. The doubleglazing has been repaired and the home is reasonably decorated. The handwritten medication records are now signed by two staff to reduce the risk of mistakes. The provider now writes a report on the homes annual survey and the manager sends a copy to the CSCI and makes it available for all interested people. Care Homes for Adults (18-65 years) Page 9 of 31 What the care home could do better The staff could make more careful checks on the way that they give and check the medication to make sure that no medication errors have taken place. When the home receives a complaint the manager should make sure that it is dealt with properly and that the person making the complaint is happy with the way it was dealt with. The manager must always keep a written record of complaints in the home. COMPLAINT Care Homes for Adults (18-65 years) Page 10 of 31 If you want to read the full report of our inspection please ask the person in charge of the care home. If you want to speak to the inspector please contact Pauline Marshall 01223 771300 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line - 0870 240 7535 Care Homes for Adults (18-65 years) Page 11 of 31 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 12 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People wishing to live at Avalon Nursing home will have sufficient up to date information to assist them to make an informed choice and the admission process is well managed. Evidence: The manager said that both the Statement of Purpose and Service User guide were reviewed and updated in August 2008. The Service User Guide uses photographs to show the facilities that are offered. People spoken with and surveyed said that both documents are easy to read and understand and that they are amended to reflect any changes in the home. There have been no new admissions to the home since the last inspection and the manager said that the initial assessment paperwork for people that have lived in the home since it opened has been archived. The assessment document that will be used for all future admissions looks at all aspects of care including a persons social and emotional needs, it has provision to record a persons abilities and the levels of support needed at the assessment stage. The manager said that people moving into the home will have a review of their initial assessment after three months to decide if Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: the home suits them. Each person living in Avalon has a license to occupy, which sets out his or her terms and conditions with the home. Care Homes for Adults (18-65 years) Page 14 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People will be fully involved in the preparation of their support plans and their opinions and wishes will be consistently sought. People will be supported to take appropriate risks. Evidence: Three support plans were examined and they all contained care plans for each area of identified needs. There were clear instructions for staff on the levels of support individuals required, for example, details of one persons communication care plan states to speak slowly, using good eye contact to encourage attention and to use proper names so that the person will learn from them. It was clear after speaking to people using the service and members of staff that people living in the home and their relatives are very involved in formulating their care plans. The daily notes were informative and detailed. All of the support plans examined were regularly reviewed and amended as required. The manager said in her annual quality assurance assessment (AQAA) we have Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: regular house-based meetings and information is gathered from other relevant people when reviewing support plans. Avalon holds regular house meetings where peoples opinions in relation to the running of the home are sought. People spoken with said they were able to choose what to do with their time and to decide what to eat and where to go. Staff were observed offering people living in the home a variety of options throughout the inspection. Bedrooms were personalised and people said they enjoyed choosing soft furnishings and other items for their rooms. All three care files examined contained risk assessments in areas such as, moving and handling, pressure area care, medication and leisure activities; each identified risk had clear plans on how they were to be managed and were regularly reviewed. Care Homes for Adults (18-65 years) Page 16 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People will partake in appropriate activities both in the home and in the local community. People will be provided with a healthy balanced diet of their choosing. Evidence: Three care files were examined together with their corresponding weekly opportunities sheets and they all contained evidence that regular activities including shopping trips, theater trips, meals out and visits to the local park take place. People spoken with said they go to the local supermarkets to buy fresh foods and that they enjoy regular outings to Brewsters pub for a meal. Members of staff said in their surveys we take people out and would like to have more staff on shift for extra one to one time. People living in the home have access to a qualified aromatherapist on a weekly basis, several people take this up and when spoken with they said how much they enjoyed it. People said that a music man comes to the home and that they enjoy listening to him. The manager said in her AQAA that the music man visits the home fortnightly. Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: People are supported to take an annual holiday and places attended in the past include Herne Bay, Margate and Hemsby. People spoken with said they looked forward to their holidays. People are encouraged to maintain their family relationships and one person living in the home regularly goes home for a couple of days at a time. People spoken with talked of their experiences with friends and family and the manager said in her AQAA we have arrangements in place to support people if they wish to embark on a personal relationship. The support plans showed that people living in the home had responsibilities within it and that daily tasks were shared by all that are able. People using the service and members of staff spoken with said that everybody is involved in the running of the home and that they help with cleaning, cooking and sometimes in warmer weather the gardening. The home operates a four-week rolling menu that is adapted to suit the requirements of the people living there. There is an alternative menu offering several different options for each of the meals on the main menu. People spoken with said that the food is good and they have what they like and that they help shop and cook. There were risk assessments in place with regard to food handling and these included, purchase, storage, preparation, cooking, cooling and re-heating of foods; there were clear instructions to staff for all areas of identified risk. The manager said that although people go to the local supermarkets for fresh foods, the heavy shopping is purchased on-line and delivered direct to the home. Care Homes for Adults (18-65 years) Page 18 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People can be assured that their personal and emotional health will be catered for and that they will receive care in their preferred way. Some shortfalls in the medication procedures could place people at risk of possible medication errors. Evidence: The three care files sampled demonstrated that peoples abilities were considered to be as important as their support needs; all of the care files showed clearly what each person was able to do for themselves and it provided detailed information on the support required. Members of staff spoken with said that they felt that they provide people living in the home with very good care and a good atmosphere. People spoken with confirmed that the home is a happy home and comments in their surveys confirmed this. People were observed throughout the inspection and they appeared happy relaxed and comfortable in staffs presence. Each of the care files examined contained full details of health appointments including chiropody, GP visits and optical and dental appointments. There was evidence of the input of specialists such as the Speech and Language and Behavioural Therapy teams. One person living in the home uses Makaton signs to help them communicate with others. Each person had a completed health action plan and an individual yearly health Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: plan that includes regular inoculations against the flu virus. People spoken with were happy with the healthcare support they receive at Avalon. A relative said in their survey every care has been taken and although my relative is unable to speak, we are very pleased with their care and attention, they have progressed since living at Avalon. The manager operates a bottle to mouth medication system and all medication is ordered, received and administered by the qualified nurses; an administration sheet is used for recording medication given or refused and there is a coding system to identify the reasons why any medication is not given. There is a list of names and signatures and the initials of all of the people that administers medication in the medication folder together with PRN (as and when required) medication protocols for all as and when prescribed medication describing how, when and why it is to be given. The manager said that her deputy regularly undertakes audits of the medication and that each bottle or pack has a start date written on the label. A random check was carried out on four medication records and their corresponding medication and three were found to be incorrect; one packet of tablets had three missing, another had one tablet too many and the third had ten tablets in the bottle when according to the check there should not have been any. The manager said that she would review her method of checking medication and the way it is administered to make sure mistakes are not happening. The manager said that all qualified staff would be involved in any changes made as a result of this review to ensure that they know how to carry out medication checks effectively. Care Homes for Adults (18-65 years) Page 20 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People can expect their complaints to be listened to but the procedures currently used do not provide people with satisfactory outcomes. People will be protected from harm and abuse. Evidence: There has been two complaints since the last inspection, both were recorded in the complaints folder; neither of the complaints included details of their outcomes. The manager said that the first complaint was dealt with but there was no evidence available to show that the complainant was satisfied with the homes response. The documentation for the second complaint showed that a senior manager had attempted to telephone the complainant but had not been successful; there was no further information on the file and the manager said that she was not sure if it had been resolved. The complaints procedure had been reviewed in May 2008 and it included the CSCI contact details but was not clear about CSCI s involvement in the homes complaints procedure. The manager said that she will review her complaints documentation after she has obtained the CSCI guidance on our website. The homes abuse procedure was reviewed in May 2008 and was clear about the actions staff needed to take if they suspected abuse. Members of staff spoken with were very clear about safeguarding issues and said that they had POVA (protection of vulnerable adults) training and were being put forward for refresher training in the New Year. The manager said that safeguarding training was organised by the company and that each time it was scheduled staff were booked to attend and that this training Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: was on going to ensure that staff had regular updates. Care Homes for Adults (18-65 years) Page 22 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People will live in a safe, homely, comfortable and clean environment. Evidence: A tour of the premises took place and all doors that had keep locked signs on them were locked; the manager had the keys on her person throughout the inspection and showed that each cupboard was neatly stacked with appropriate items. Equipment such as hoists was stored safely away when not in use and each side of the home had a locked store cupboard for its cleaning materials. The manager said in her AQAA the building has been recently redecorated with any surfaces damaged by wheelchair collision repaired. It was noticed on the day of the inspection that there was quite a lot of wheelchair damage to the walls and doors around the hallway areas. The manager said that this was recently damaged and that it is due for repair and decoration again in January 2009 and that protective strips will be fitted to try to alleviate the problem, as this is constantly requiring attention. All of the bedrooms were nicely decorated and people had their own personal possessions around them. There are two assisted baths and two shower rooms for people to use and they were all in working order with evidence of regular servicing. The home was clean, pleasant and hygienic throughout. Care Homes for Adults (18-65 years) Page 23 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People will be supported by competent, well trained and supported staff. The home operates a robust recruitment procedure. Evidence: There are qualified nurses on duty twenty four hours a day and they are supported by three care staff throughout the daytime; one qualified nurse and one care staff are awake at night. The manager said that she has two supernumery days in which to carry out her managerial duties; the other three days she is the qualified nurse on the shift. The rosters confirmed that Avalon has sufficient staff on duty to meet the needs of the people living in the home. Members of staff said in their surveys that they would like additional staff on some shifts to enable more one to one time to go out. Three staff files were examined and mostly contained the required documents; the shortfalls were for people that had been employed by the health trust in 1993 and one persons supervision file could not be located and the manager said that the staff member might have the folder himself or herself. The other two staff files contained evidence of regular supervision taking place and the manager said that she aims to provide supervision every four to six weeks; staff spoken with confirmed that regular supervision takes place. There was evidence of induction for the most recently employed staff member and induction paperwork for an employee that started work on the day of the inspection had been completed. Each staff file contained a declaration of Care Homes for Adults (18-65 years) Page 24 of 31 Evidence: their fitness and a criminal records bureau check. The manager keeps profiles for all of the agency staff employed in the home and she said in her AQAA that profiles are now sent to the home by e-mail direct from the agency. There was evidence that agency staff had received supervision. Family Mosaic provides staff with training at regular intervals and staff are booked to attend. The training file contained many certificates to confirm that regular training takes place and the manager has prepared a training matrix to ensure that people have regular updates. In the past year training has been provided in diversity, fire safety, food hygiene, manual handling, personal safety, safeguarding, first aid, Deprivation of Liberty and Mental Capacity Act awareness. Staff members spoken with said that training opportunities are good and people said in their surveys staff are competent and well trained. Five of the homes staff have NVQ level 2 or above and one of the deputy managers has completed the NVQ level 4 . Care Homes for Adults (18-65 years) Page 25 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People live in a well run home where their health and safety is protected. Evidence: The manager of Avalon has worked at the home for sixteen years and is a qualified nurse and she has attained the Registered Managers Award; she regularly updates her practice and has had training in the past year in safeguarding, fire, the Mental Capacity Act, Deprivation of Liberties, assistive technology and moving and handling. People spoken with were very complimentary of the manager and said that she is very supportive and has a positive and proactive outlook. An annual quality assurance survey is carried out by Family Mosaic and a report is devised and made available to people wishing to see it. The home has its own systems for measuring quality including having regular meetings for staff and people living in the home and audits on medication, health and safety checks and the use of a cleaning rota to ensure household tasks are not missed. All health and safety certificates were in place and up to date; the fire risk assessment Care Homes for Adults (18-65 years) Page 26 of 31 Evidence: was reviewed in April 2008 and regular fire drills take place; the last one occurred on 30/11/08. Care Homes for Adults (18-65 years) Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 28 of 31 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 20 13 The manager must make sure that all medication audits on medication received in the home are carried out correctly. 27/02/2009 To ensure that people are not at risk of medication errors. 2 22 22 The manager must make sure that all complaints are fully investigated and the outcomes recorded. 27/02/2009 To ensure that all complaints are fully dealt with to the complainants satisfaction. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 29 of 31 Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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