Inspection on 24/11/05 for Berry Hill Care Home

This inspection was carried out on 24th November 2005.

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

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

Other inspections for this house

Berry Hill Care Home 20/06/07

Berry Hill Care Home 26/06/06

Berry Hill Care Home 18/07/05

Berry Hill Care Home 15/11/04

Berry Hill Care Home 25/05/04

Berry Hill Care Home 07/01/04

Berry Hill Care Home 11/12/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Berry Hill Care Home Berry Hill Lane Mansfield Nottinghamshire NG18 4JR Lead Inspector Steve Keeling Unannounced Inspection 24th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Berry Hill Care Home Address Berry Hill Lane Mansfield Nottinghamshire NG18 4JR 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) 01623 421211 01623 428864 Southern Cross Care Homes No 2 Limited Dorothy Ann Turton Care Home 63 Category(ies) of Old age, not falling within any other category registration, with number (63), Terminally ill (1) of places Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users shall be within categories OP with 1 bed registered for TI One Service user may be aged 64 years as named in application dated 24/5/05 PD 18th July 2005 Date of last inspection Brief Description of the Service: Berry Hill Park Care Centre is a 63-bedded care home providing nursing and residential care, owned by Southern Cross Healthcare . It is a two-storey building within extensive grounds. The building is situated on a main road with access to public transport and a direct bus route to Mansfield, which is three miles away. The accommodation was originally divided into two wings but is now regarded as one whole unit. Accommodation consists of a total of 48 single rooms, all ensuite except one and eight double rooms, all ensuite. Staffing provision is primarily by qualified nurses and care assistants for nursing service users and senior carers and care assistants for service users who receive personal care only. The care manager is responsible for the whole complex. There is a car parking facility at the front of the home and an enclosed, fenced garden at the rear, which overlooks a large field, used by the general public. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a 7-hour period and involved one inspector. The inspection was in response to an anonymous complaint received at the Commission for Social Care Inspection in relation to care afforded to service users, and the staffing levels at the home were inappropriate to meet the needs of the service users. The main method of inspection was case note tracking, this is a method of selecting service users within the home and discussing with them their expectations and experiences of living within the home environment. The case tracking method also analyses the records of the service users to ascertain if the service users identified needs are being addressed appropriately within the care home setting and that their safety and well being is being maintained. On this occasion two service users notes were case tracked and two service users were spoken with, the inspector also discussed the care afforded to service users at the home with two service users relatives who were visiting the home on the afternoon of the inspection. The home has been recently acquired by Southern Cross in March 2005 and is now undertaking a scheduled refurbishment to upgrade the home. At the time of the inspection a total of 55 residents were accommodated at the home. The manager within the unit was very helpful and cooperative thus ensuring that the inspection process progressed in a professional and efficient manner. What the service does well: Service users spoken with expressed a great deal of satisfaction with the care afforded to them at the home and stated that their needs were being met. Overall the homes environmental standards are good and it was evident that the planned refurbishment is progressing effectively. Service users are encourage to take an active park in the development of the home and are encouraged to attend a residents meeting on a bi-monthly basis. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 6 A good level of training is provided at the home with the support of the new owners. Care staff were observed to be courteous and interactive with service users. In ensuring that service users are safe within the homes environment the manager could evidence comprehensive maintenance schedules. It was evidenced that staffing levels are sufficient to meet the needs of the service users. What has improved since the last inspection? What they could do better: Evaluation and care planning documentation introduced by Southern Cross Health Care is now being utilised at the home but the case tracking process identified significant shortfalls in both the evaluation and care planning process and as such the health care needs of the case tracked service users was not being addressed effectively at the home. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 7 It is a requirement that the Commission for Social Care Inspection is informed of all significant events relating the care of service users at the home. It was evident that on occasions this function is not being performed effectively. 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. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. 3. 6. Service users have a written contract / statement of terms and conditions within the home. Not all service users documentation evidenced pre-admittance assessments and as such it could not be assured that identified needs are met at the home. Berryhill Care Home does not provide intermediate care services. EVIDENCE: The service users guide and statement of purpose is on display within the foyer of the home but it was established that the documentation is from the previous owners, Highfields Health Care. Southern Cross Health Care, the new owners of the home, are currently in the process of re-printing the service user guides and statement of purpose and once the new documentation is available it will be distributed to service users at the home. Service users contacts of residency are securely stored in the administrators office to ensure service users confidentiality is maintained. Once again the Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 10 contacts of residency are to be amended in the near future by the Southern Cross organisation. It was established that it is the intention of the manager, once the revised contacts are available, to continue the store service user contracts in the administrators office to ensure confidentiality is maintained. Documentation examined through the case tracking procedure did not evidence pre admittance assessments. The manager of the unit stated that the assessment procedure had taken place but as new documentation provided by Southern Cross Health Care had been introduced the pre-admittance assessments had not been “brought forward” to the new documentation. In the absence of a pre-admittance assessment documentation the inspector could not establish if the initial needs of the service users had been addressed effectively at the home. An immediate requirement was issued at the time of the inspection to ensure all service users have their pre-admittance assessments evidenced within their care planning notes. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. 8. 10. 11. The case tracking procedure established that the care plans examined did not fully address the health needs of the service users and as such it could not be established that health needs were being fully met at the home. Service users spoken with stated that staff at the home maintains respect and dignity. The case tracked notes did not evidence that issues relating to the time of death was discussed with the service user or their representatives. EVIDENCE: The case tracking procedure revealed that two service users who had sustained scalds did not have care plans formulated to address the management of the wounds. No risk assessments had been formulated to ensure the service users would not be at risk of scalding in the future. The first case tracked service user had sustained a scald to the right hip. The scald was documented in the daily progress report on the 11th November 2005. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 12 The wound was described as a 12 x 10cm skin loss and the next of kin have been informed. It was evident from information gleaned from the service users daily information record that the wound was deteriorating and the entry dated 22nd November 2005 stated that the wound was “healing from the outside but sloughy in the middle with yellow discharge. In the presence of the homes manager, a senior member of the nursing staff informed the inspector that the wound was now healing well and dry. The inspector was also informed that a referral had been made to the Specialist Tissue Viability nurse for advice and she would be reviewing the wound on Monday 28th November 2005 or Tuesday 29th November 2005. The manager of the home inspected the wound in the presence of the inspector and it was established that the wound was actually wet, sloughy in the middle, malodorous and inflamed, at that time a photograph of the wound was obtained by the manager as requested by the inspector. No documentary evidence was available within the service users notes to substantiate the referral to the Tissue Viability Nurse. The Tissue Viability Nurse was contacted at 1620hrs and the inspector was informed that she had not received the referral for the service user but admitted that some referrals are occasionally mislaid. It was established that the service user had not been referred to her general practitioner either for advice and instructions in the management of the wound. The manager of the home contacted the Tissue Viability Nurse at approximately 1700hrs on the 24th November 2005 requesting an evaluation of the wound and it was established that the specialist nurse would review the wound on the morning of 25th November 2005. A request for a General practitioners intervention was also made by the manager of the unit. The second case tracked service users had sustained superficial burns to her fingertips on her right hand on 30th October 2005, once again no care plan or risk assessment had been performed to evidence that the wounds had been effectively managed, although on examination of the wounds in the presence of the manager it was evident that the injuries had almost healed. Both case tracked service users had elevated Waterlow Scores (Waterlow is a tool to determine an individuals susceptibility to the formation of pressure ulceration). Care plans were not evident in either of the case tracked notes to evidence that the appropriate interventions are taking place to minimise the risk of pressure ulcer formation. One case tracked service user had been assessed as doubly incontinent but no care plan could be evidenced to demonstrate that this distressing condition was being managed effectively at the home. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 13 One case tracked service users had been assessed as being “high risk” in relation to moving and handling. Once again no care plan was evident in the service users notes to demonstrate that the condition was being effectively managed, as such a potential risk of injury for both service users and staff alike within the home was established. One case tracked service users notes highlighted the need to perform monthly weight checks due to concerns in relation to the service users nutritional intake, once again the weight monitoring documentation supplied by Southern Cross Health Care had not been utilised, as the documentation was completely blank. Care plans that were evident within the service users documentation did not have times scales for re-evaluations although it was evident that the care plans were being re-evaluated on a monthly basis. The home maintains daily progress documentation for all service users in which elements of care identified in care plans should be evaluated effectively. It was evident that the evaluation process was not effective. On 23rd November 2005 the daily evaluation of the care afforded to one case tracked service users was recorded as “usual day” which is not an effective evaluation of the care plans. In addressing the aforementioned shortfalls the manger of the home will initiate the Southern Cross documentation audit to ensure the identified shortfalls are addressed effectively, it is also the intention of the manager of the home in conjunction with the Southern Cross area manager to initiate an investigation appertaining to the care afforded to the two service users who sustained scolds at the home. The outcome of the investigation will be forwarded to the Commission for Social Care Inspection. It was evident that service users are afforded appropriate privacy, dignity and respect within the home environment. Service users and relatives spoken with were very complimentary about the way staff spoke to them. It was evident that staff always knocked on the resident’s bedroom door before entering. The manager at the home has issued all care staff with small signs which are placed on the service users doors when personal interventions are taking place to ensure no one enters the room at these times thus further promoting the principles of privacy, dignity and respect at the home. Service user spoken with also stated that the staff respected their privacy and dignity when bathing or performing personal care and that all staff within the home are very pleasant, friendly and attentive to their needs. The case tracked notes did not evidence that issues relating to the time of death are discussed with the service user or their representatives. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 14 It was established and indeed evidenced by the manager of the home that this had been discussed at the residents meeting performed on 4th August 2005, it was established that residents stated that they would find it offensive to discuss these matters and as such the manager does not address them at the time of admission. At the time of the inspection no service users were in the final stages of life but it was established that the Liverpool Care Pathway Care Plans, which is a government-led initiative to improve the quality of life for service users at the end of their life are utilised as required at Berryhill Care Home. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 to 15 were not inspected on this occasion. EVIDENCE: Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. The manager of the home, in ensuring that service users are protected from abuse initiates the Southern Cross Complaints and investigation procedures appropriately but shortfalls in the reporting if significant events to the Commission for Social Care inspection was evident. EVIDENCE: At the previous inspection it was noted that the manager of the home was not fully conversant with adult protection reporting procedures and as such she would be required to familiarise herself with the procedure. It was established that significant events appertaining to the two case tracked service users were not reported to the Commission for Social Care Inspection which indicates that the manager would benefit from further training in relation to adult protection reporting. As such the manager will be required to evidence further training opportunities for herself to address this shortfall. It was ascertained that not all staff at the home have undertaken training in adult protection issues although it was established that Southern Cross Health Care group now supplies ongoing in-house training opportunities which does include training in relation to the protection of the vulnerable adult and as such staff will receive the training in the near future to rectify this shortfall. At the time of the inspection service users and relatives were spoken with, they felt confident that the manager and the care staff would always address any complaints in a sensitive and professional manner and the service users together with their relatives stated that they would not hesitate to discuss any Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 17 concerns in relation to the care afforded to them within the home environment. It was established that service users within the home felt safe and protected. At a previous inspection it was reiterated to the manager that all volunteers must undergo the same recruitment process as employed staff to ensure the safety and wellbeing of the service users. As such volunteers at the home now have POVA first (Protection of Vulnerable Adult List) and Criminal Record Disclosures before unsupervised interventions with service users take place. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 to 26 was not inspected on this occasion. EVIDENCE: Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27. The number and designation of staff employed within the home is sufficient to meet the needs of the 55 service users. EVIDENCE: Staff employed at Berryhill Care Home is sufficient to meet the needs of the service users and an appropriate skill mix was evidenced. The manager of the home specified that ideally, nine carers and one qualified nurse are employed throughout the morning period, eight carers and one qualified nurse covers the afternoon period and throughout the night the home employs 4 care staff and one qualified nurse. It was evidenced that the manager and her deputy manager have initiated a 24 hour an call rota to ensure that a senior member of staff is available should any emergencies develop of the home. On the morning of the inspection six carers, two senior carers and one qualified nurse was on duty, throughout the afternoon period six carers, two senior carers and one qualified member of staff was on duty and the night period was covered by five carers and one qualified nurse. The Commission for Social Care Inspection had received and anonymous complaint regarding staffing levels on the morning of the 21st November 2005. An examination of the staffing rotas for that day evidenced that the staffing levels were appropriate to meet the needs if the service users but the inspector Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 20 was informed that two staff members did not managed to report for morning duty on time as their vehicle had broken down due to the severe weather conditions experienced on that day. It was evident that the delayed staff did report for duty approximately one hour after the morning shift had commenced. At a previous inspection a requirement was made to undertake a staffing review to ensure service users needs are met by sufficient levels of staff at all times as a response to a high level of falls reported in the evening period. The manager has performed the staffing review and it has been decided that two new posts will be created for carers between the hours of 1800hrs and 2230hrs. It was established that the two posts have now been filled, one carer is currently on her induction period and the second carer will commence employment once all relevant documentation has been received mby the manager and has been deemed as satisfactory. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38. The manager at Berryhill Care Home with the support of Southern Cross Health Care ensures that the health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: In ensuring the health, safety and welfare of service users and staff are promoted within the environment of Berryhill Care Home, the manager utilises the “in house” training opportunities provided by the Southern Cross Health Care group. Staff at the home receive appropriate training in fire fighting methodologies, moving and handling education, health and safety training and food hygiene training. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 22 Senior members of staff have also received enhanced training opportunities from a local college in the form of distance learning packages in relation to health and safety so that the senior members of staff can disseminate information to the junior staff members employed at the home. It was evidenced that the home is maintained to a satisfactory standard throughout and it was determined that appropriate precautions are taken in relation to the control of Leginalla contamination, the testing of emergency lighting, the testing of fire equipment and fire alarms. It was also evidenced that the home performs appropriate maintenance schedule on all equipment designed of aid mobility such as wheelchairs, hoists and specialist baths. It was evidenced that electrical equipment utilised within the home had undergone the Portable Appliance Test (P.A.T) to ensure that it is in good working order and safe. The manager of the unit could also demonstrate that bed rail checks are performed on a monthly basis, hot water outlet checks are performed on a monthly basis and window restrictor checks are also performed on a monthly basis together with the staff call system which is also checked monthly. The records appertaining to the all the aforementioned issues were clear, concise and well maintained. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x X X X X X X 3 Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 3 Regulation 14 (1) (a) Requirement The registered person shall ensure a suitably qualified or suitably trained person has assessed the needs of the service users. The registered person shall ensure after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. The registered person shall keep the service users plan under review. The registered person shall make arrangements for service users to receive where necessary treatment, advice and other services from any health care professional. The registered person shall make arrangements by training staff or by other measures to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person shall give DS0000040343.V267882.R01.S.doc Timescale for action 01/12/05 2 7 15 (1) 24/12/05 3 4 7 8 15 (2) (b) 13 (1) (b) 01/12/05 01/12/05 5 18 13 (6) 02/01/06 5 18 37 (c) 01/12/05 Page 25 Berry Hill Care Home Version 5.0 notice to the commission without delay of the occurrence of any serious injury to the service users. 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 Refer to Standard 1 7 Good Practice Recommendations All service users should be issued with an individual copy of the service users guide when available. Care plans and risk assessments should be reviewed monthly to ensure health-promoting interventions are performed appropriately. Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Berry Hill Care Home DS0000040343.V267882.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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