Inspection on 05/12/07 for Aykroyd Lodge

This inspection was carried out on 5th December 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aykroyd Lodge 05/12/06

Aykroyd Lodge 01/11/05

Aykroyd Lodge 10/05/05

Aykroyd Lodge 30/11/04

Aykroyd Lodge 20/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Aykroyd Lodge The Crescent Reedley Nr Burnley Lancashire BB10 2LX Lead Inspector Mrs Julie Playfer Unannounced Inspection 5 December 2007 09:15 th Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 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 Aykroyd Lodge DS0000054542.V352523.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 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. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aykroyd Lodge Address The Crescent Reedley Nr Burnley Lancashire BB10 2LX 01282 449004 01282 698920 aykroyd@reedley4321.fsnet.co.uk 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) Voyage Ltd Ms Kate Louise Openshaw Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for six service users in the category of LD (Learning Disability under the aged of 65). 5th December 2006 Date of last inspection Brief Description of the Service: Aykroyd Lodge is registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to six adults (aged 18 - 65) with a learning disability. The home comprises of a large detached property, set in its own grounds, in a residential area in Reedley, Burnley. Spacious accommodation is provided in six single bedrooms, all of which have an ensuite facility. There are two lounges, a dining room and a dining kitchen. The garden is extensive, well maintained and accessible to residents. There is wheelchair access to the home at the main entrance, which is on the side of the building. There are limited car parking facilities. The home is located approximately half a mile from Brierfield town centre. The home has a statement of purpose and service users guide, which informs the current and prospective residents about the services and facilities available at the home. At the time of the inspection the level of fees ranged from £1,011.06 to £2,219.64 per week. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Aykroyd Lodge on 5th December 2007. During the visit the inspector looked at written information including policies, procedures and records, spoke to and observed the residents, spoke to the registered manager and staff and conducted a partial tour of the premises. As part of the inspection process the inspector used “case tracking” as a means of gathering information. This process allows the inspector to focus on a small group of people living at the home. Prior to the inspection satisfaction questionnaires were sent to the home. One questionnaire was returned from a relative and three questionnaires were received from the staff. The registered manager also completed a detailed factual questionnaire (Annual Quality Assurance Assessment) about the home. Information from the questionnaires was collated and used as evidence throughout the inspection process. At the time of the inspection there were 5 people accommodated in the home, plus one additional person going through the transition of leaving the home. What the service does well: The residents were provided with useful information about the home, which was explained by the staff team. The residents’ needs were properly assessed and reviewed at regular intervals. This meant the staff were aware of the residents’ current needs and how best to provide care and support. Care and support was planned effectively to ensure the residents’ needs were met. The residents pursued a range of activities both inside and outside the home. This approach enabled the residents to participate in the life of the home and gave them the opportunity the meet other people. The residents were provided with varied and nutritious food, which took account of their personal preferences. The residents’ healthcare needs were met and specialist advice was sought as necessary. Personal support was responsive to the varied and individual preferences of the residents. Arrangements were in place to ensure any concerns of the residents were noted and acted upon. The residents were provided with a clean, comfortable and safe environment, which was decorated in line with their personal tastes and preferences. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 6 The recruitment and selection procedures protected the residents and ensured that all new staff were fully vetted. The staff were provided with good training opportunities, which were relevant to their role. Appropriate systems were in place to monitor the quality of the service and the health and safety of the residents was promoted and protected. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 7 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. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were provided with appropriate information about the services and facilities provided in the home and their needs were properly assessed and reviewed. EVIDENCE: Written information was available for residents in the form of a service users guide and statement of purpose. Both documents met regulatory requirements and had been written in accessible format with the use of pictures and symbols. The statement of purpose and the service users guide were explained by the staff team, as appropriate. All residents living in the home had been established for sometime and there had been no new residents admitted into the home, since the last inspection. It was evident from the case tracking process that the residents’ needs had been appropriately assessed prior to admission and the assessments had been kept under review. There was a comprehensive admission process, which involved transition plans and a detailed assessment of needs. All residents had been issued with a contract, which detailed their terms and conditions of residence. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ individual needs were addressed and they were consulted about their daily choices. EVIDENCE: The case tracking process demonstrated that each person had an individual plan, which reflected their health and welfare needs. The plans were supplemented by risk assessments, behaviour management strategies and a variety of records including care provided, activities, medical and evaluation sheets. Since the last inspection, the care planning format had been revised and updated. The new format was easy to read and understand and included clear guidance for staff to ensure all needs were met. The plans were reviewed at least every six months with the resident, where appropriate and any supporter or professional who needed to be involved. The reviews included a detailed report compiled by the residents’ keyworkers. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 11 The people living in the home were supported to take responsible risks. Detailed risk assessments and management strategies covered activities indoors and in the wider community and were included in the residents’ care plan documentation. The risk assessments included control measures in order to minimise or eliminate the assessed risk. During the inspection, it was evident the residents were consulted about their choice of activity, food and drink. Staff were observed to carefully explain what options were available to the residents. The residents were supported with the financial affairs and detailed written records were maintained of all transactions. A random check of money deposited with the home for safe keeping corresponded accurately to the records. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were provided with good opportunities to engage in a wide range of activities. EVIDENCE: Individual plans and records demonstrated that residents had opportunities to maintain and develop practical life skills. Residents were encouraged and supported to participate in the life of the home and carried out small tasks commensurate with their abilities. For instance one person was asked if he would like to assist with some household tasks during the inspection. The residents pursued an extensive range of activities both inside and outside the home. The activities were detailed on a board in the office and wherever possible each resident was given the opportunity to go out at least once a day. Staff spoken to confirmed that care was taken to ensure each resident could pursue activities on an individual basis. The activities were evaluated to Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 13 monitor the residents’ level of participation and enjoyment. Records were maintained of all completed activities. Activities outside the home included; drives round the local area, swimming, gateway club, going to football matches, horse riding, bowling and dance classes. The staffing levels allowed for both individual and group activities. On the day of inspection, one person went shopping, one person went to the bank and two people went to dance classes. Since the last inspection, the residents had been away on holiday to Blackpool, in two separate groups. The residents were supported to maintain good contact with their families. As such friends and family were welcome to visit the home at any time convenient to the residents. The residents also visited their families on a regular basis. The registered manager explained that plans were in place to invite the residents’ relatives to a Christmas party. The relative who completed a questionnaire indicated that they were satisfied with the level of care and support provided. The residents had unrestricted access to the home and grounds. The residents were also able to use their room at any time should they wish to spend some time in private. The meals followed a weekly menu, which was prepared two weeks in advance. The menus were varied and residents were provided with an alternative, if they didn’t like the main option. Since the last inspection, each resident had been assessed by a speech therapist. The results of the assessment had been set out in a meal time information sheet. The sheets provided useful information for the staff including details about the person’s positioning, equipment needed, the risks associated with meal times and likes and dislikes. The staff maintained individual records of meals provided to the residents. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ healthcare and personal support needs were met, however, the medication recording systems were not always consistent. EVIDENCE: The residents’ individual care plans set out the personal support and care each person required and provided details about how this support was to be delivered. There was an intimate care policy and procedure for each resident, which stressed their rights to privacy and dignity. The staff spoken to confirmed that the routines were flexible and were primarily designed to meet the needs and preferences of the residents and their plans for the day. Residents were offered personal care in a discreet and dignified manner throughout the inspection. Healthcare needs were appropriately assessed and were incorporated into the care plan documentation. Clear guidance was provided for staff on how to monitor and respond to the residents’ medical conditions. There was evidence to indicate that the residents had access to NHS services and the advice of specialist services e.g. Psychologist, Physiotherapist and Speech Therapist had Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 15 been sought as necessary. All the residents were registered with a General Practitioner. The residents were allocated with a keyworker. At the time of the inspection the registered manager was in the process of consulting the staff about the allocation of key workers and had recently introduced keyworker meetings. This enabled the staff to focus on the care provided for each resident, which ensured all needs were met and changing needs were promptly identified. There was a set of policies and procedures in respect of handling all aspects of medication. Since the last inspection, arrangements had been put into place to safely store controlled drugs and guidelines had been established for the administration of medication prescribed, as necessary. Appropriate records were maintained for the receipt, administration and disposal of medication. However, it was noted that not all current medication had been entered onto the medication administration record (MAR), handwritten entries on the MAR’s did not always include prescribing details from the prescription labels and the application of creams had not always been consistently recorded. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective systems in place to ensure any concerns of the residents would be acted upon. Written procedures and practice protected the residents from abuse and neglect. EVIDENCE: The complaints procedure was included in the service users guide and as far as possible the procedure had been explained to the residents. The residents were consulted on a daily basis about their choices and preferences. The residents, who were not able to verbally communicate their views, were closely observed and their reactions and behaviours were noted. There was evidence of these observations in the care plan documentation and the placement reviews. The registered manager had received one complaint since the last inspection. This had been recorded and fully investigated. The complaint was found to be unsubstantiated. There was a copy of “No Secrets in Lancashire” and staff had access to a whistle blowing procedure. Since the last inspection, the internal procedure for responding to any allegations, suspicion or evidence of abuse or harm had been updated and revised. The registered manager and staff had completed training courses on safeguarding vulnerable adults and were aware of the procedures and various agencies involved. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were provided with a spacious, comfortable, safe and well maintained home. EVIDENCE: Aykroyd Lodge is large detached house set in it’s own grounds. It is located in a residential area in Reedley, near Burnley. Accommodation is provided in six single bedrooms, all have which have an ensuite facility, which includes a bath. Communal space is provided in two lounges, one dining room and a dining kitchen. All rooms provide space in excess of the National Minimum Standards. The bedrooms have been furnished and decorated according to the personal taste and preferences of the residents. Since the last inspection, three bedrooms had been redecorated and one ensuite had been fitted with shower. Residents were able to use their rooms at any time should they wish to spend time pursuing their own activities. The furnishings and fittings were domestic in character and of a good standard throughout. Appropriate arrangements Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 18 were in place to carry out repairs and general maintenance. Records were maintained of all the works carried out. At the time of the inspection, the premises were comfortable, clean and free from offensive odours. Appropriate arrangements were in place for the residents’ laundry. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The recruitment and selection procedures were thorough and ensured the protection of the residents. The staff were well trained and had access to good training opportunities. EVIDENCE: Staff had been issued with a job description, which was commensurate with their role, as part of the recruitment process. From discussions with the staff during the inspection, it was evident they had a good understanding of the needs of the residents and knew the residents well. Staff referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. The staff rotas indicated that the staffing levels were regularly reviewed and additional staff were on duty, where necessary to meet the needs of the staff. Further to this it was noted that the staff who completed a questionnaire indicated that in their opinion the home was sometimes “short staffed”. There was sufficient staff on duty on the day of inspection. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 20 The recruitment and selection procedure was underpinned by the organisation’s Equal Opportunities Policy. Since the last inspection, the recruitment process had been transferred to a central office. The files of two recently employed staff were inspected. Both had completed an application form and had attended the home for an interview. Relevant checks had been obtained from the criminal records bureau along with two written references, prior to the commencement of employment. An induction training package was available for new staff, which covered the “Skills for Care” standards. Each member of staff had a training assessment and profile and there was an overall training development plan for the staff team as a whole. It was evident the staff had access to a broad range of training courses associated with the care and support of the residents. At the time of the inspection, nine members of staff had achieved NVQ level 2 or above. This equated to 64 of the staff team, which was an increase of 20 since the last inspection. A further three members of staff were working towards this qualification. Since the last inspection, the company had supplied the home with a laptop computer, known as the “EL Box” (electronic learning box). This meant staff were able to complete various training courses at their own convenience, whilst working in the home. The courses offered included health and safety, food hygiene and POVA. Staff meetings were held on a regular basis and minutes were seen during the visit. The meetings gave the opportunity to staff to share experiences and develop teamwork. A programme had been established to ensure all staff received appropriate supervision at least six times a year and had an annual appraisal of their work. The supervision process was comprehensive with detailed notes and action plans. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to monitor and develop the quality of the service and the health and safety of the residents was promoted and protected. EVIDENCE: The registered manager had overall responsibility for the management of the home and had a job description, which reflected the aims and objectives of the home. The manager had completed an NVQ level 4 in Management and was working towards NVQ level 4 in Care. Ms Openshaw had five years experience of managing care homes in various residential settings and had undertaken a variety of courses over the last twelve months. The management approach was consultative and there were established systems to consult the staff and residents on an ongoing basis. Relationships Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 22 within the home were positive and staff spoke to and about the residents with respect. The registered manager had established systems to monitor the quality of the service, which included monthly home manager reports. Satisfaction questionnaires were distributed in August 2007 and a survey had been carried out of the staff team. The results of the surveys had been collated. An annual development plan based on the outcomes of the monitoring processes had been produced, which identified the planned developments for the service. There were policies and procedures covering all aspects of health safety in the home. The staff received health and safety training, which included food hygiene, moving and handling, first aid and fire safety. According to the annual quality assurance assessment and documentation seen during the inspection the electrical, gas, heating and fire systems had been serviced at regular intervals. In addition pre set valves had been fitted to all water outlets to ensure water was delivered at a safe temperature. Hazardous substances were stored securely. The registered manager had carried out risk assessments of the environment and there was a procedure in place for the reporting of any accidents or incidents. Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 3 X Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 (2) Requirement In the event of additional medication, all details from the prescription label must be accurately transcribed on the medication administration record, including the time and dosage. The entry must be checked and witnessed by another member of staff to minimise the potential for error. (Previous timescale of 05/12/06 – not met). All current medication prescribed for residents must be entered onto the medication administration record. The application of creams must be consistently recorded and clear guidance must be provided for staff on the application of specific creams. This is to ensure the residents receive their medication in line with the prescribers’ instructions. Timescale for action 05/12/07 2. YA20 13 (2) 05/12/07 Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Aykroyd Lodge DS0000054542.V352523.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!