Inspection on 15/12/06 for Birkdale

This inspection was carried out on 15th December 2006.

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

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

Other inspections for this house

Birkdale 21/10/08

Birkdale 15/06/06

Birkdale 16/02/06

Birkdale 24/05/05

Birkdale 03/12/04

Birkdale 01/07/04

Birkdale 12/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Birkdale Station Hill Oakengates Telford Shropshire TF2 9AA Lead Inspector Joy Hoelzel Key Announced Inspection 15th December 2006 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 Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birkdale Address Station Hill Oakengates Telford Shropshire TF2 9AA 01952 620 278 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) The Keepings Ltd Miss Rebecca Elizabeth Lambourne Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 29 persons, whilst the person named on the attached schedule (not to be displayed) is resident. 15th June 2006 Date of last inspection Brief Description of the Service: Birkdale, one of two homes owned by The Keepings Ltd, is a care home providing accommodation and personal care for up to twenty-eight people over the age of sixty-five. Situated close to Oakengates town centre it is accessible to a variety of local amenities and public transport. A large, two-storey, detached property it provides single and twin-bedded accommodation with communal sitting/dining areas. There is generous car parking space to the front and a sheltered garden to the rear. Access to the rooms on the first floor is facilitated by a passenger lift. Weekly fees range from £345.90 -£354.00. Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are readily available. Commission for Social Care Inspection Reports for this service are available from the provider or can be obtained from www.csci.org.uk Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced key inspection is the second of the statutory inspections for 2006/07 and took place over four and half hours on Friday 15th December 2006. It was conducted by two regulation inspectors. Twenty-six of the thirty-eight National Minimum Standards for Older People were inspected on this occasion. Twenty people are currently living at the home, staffing numbers were observed to be at satisfactory levels. Six case files were selected for case tracking, relevant documents and procedures were inspected, together with a selection of staff personnel files. On site surveys were distributed to service users, staff and visitors, eleven were completed and returned to the inspector at the end of the inspection. A full tour of the premises was conducted. A specialist random inspection was conducted by the pharmacy inspector on 21st December 2006, the findings of his inspection are included in this report. What the service does well: What has improved since the last inspection? All of the requirements issued following the last inspection have been complied with, barring the requirements in relation to medication. The pharmacy inspector has been requested to visit the home again to check the compliance with the requirements in this area. The findings of his inspection on 21/12/06 are included in this report. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 6 Improvements have been made to recording information in the care plans this gives staff the information they need to offer a consistent approach to ensuring care needs are fully met. Improvements have been made to the environment and to ensuring the health, welfare and safety of service users, staff and visitors is upheld. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 1,2 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available which should enable prospective service users (or their ‘agents’) to reach an informed decision about entering the home. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. EVIDENCE: There were two ‘Requirements’ arising from the previous Inspection. These related to Resident’s contracts of terms and conditions, and for needs assessment forms to show full details of the pre-admission assessment. ‘Case Tracking’ involving review of 6 Residents’ Care Plans/Files (i.e. those relating to the two most recently admitted service users, plus four selected at random) and discussion with service users and visitors provided the following evidence: - Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 9 Prospective service users, or their representatives, are now provided with the information needed to make an informed decision as to whether the home is able to meet their needs and, if necessary, are informed about changes in the cost of their care. All ‘case tracked’ service users or their representatives, had received a copy of their service provision contract, and, where necessary, had been informed in writing of any changes in that contract since entering the home. Processes to ensure appropriate and thorough care needs assessment had been effectively applied by the manager, or deputy, prior to admission thus enabling an informed decision by Residents/Representatives regarding the home’s capability of meeting their individual care needs. The requirements were therefore found to be fully met. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The model of care plan utilised by the home is of a comprehensive design and easy to read. The care provided by the home is effective in meeting service users assessed care needs, and is delivered considerately and effectively. Service users are treated with respect and their privacy and dignity is upheld. EVIDENCE: At the previous Inspection a number of ‘Requirements’ were cited under standards relating to ‘Health and Personal Care.’ Three were in relation to the design and utilisation of individual care plans, two were about how service users are enabled to make decisions about controlling their own lives, and one under the heading ‘privacy and dignity’, which related specifically to the need to install ‘engaged’ indicator locks on toilets and bathrooms, plus the addition of a locking facility for individual bedrooms. A further group related to the management and administration of medicines. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 11 As a component part of the ‘Case Tracking’, 6 service users’ Care Plans/Files were reviewed and discussions held with the respective service users, in addition to discussions with the manager and staff, and observation by the Inspectors. The Inspectors found that there have a number of significant developments in the design of care planning documentation since the previous Inspection, particularly in relation to ‘moving and handling’, and ‘nutritional state’ assessment. All areas of the documentation were seen to be reliably completed, up-to-date, and with evidence of month by month review by the manager. A tour of the home by the Inspectors found that all ‘communal’ toilets and bathrooms now benefit from indicators, which show when they are in use and, those Residents who are assessed as capable, and who so wish, can lock their bedroom doors. Two service users spoken with confirmed that they hold the key to their bedroom door and lock the door when they are out of their room. Based on this evidence the Inspectors were able to conclude that the requirements not related to medicines had been met. The Pharmacist Inspector visited on the 21st December 2006 to assess what progress the home had made in meeting the requirements made following the pharmacy inspection carried out on the 28th July 2006. The procedures document for the handling of medicines was again reviewed and it was seen that the content was still not sufficient to make the document a comprehensive description of how medicines were handled within the home. The home was asked again to review, update and describe in more detail the practices expected to be undertaken by the staff. The document at the very least must describe in detail how the home carries out the following: Ordering prescriptions. Checking prescription prior to dispensing. Checking and recording the receipt of medication. How and where medication is stored and the monitoring requirements. How medication is administered to the residents. What records are kept within the home. How medicines are disposed of safely. Management of self-administration by residents. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 12 Use Homely Remedies. Protocol authorised for each resident by his or her GP. Management of errors in the administration of medication. Management of residents requiring the administration of medication via specialised techniques. The receipt, administration and disposal of Controlled Drugs. Managing the need to supply medication for administration away from the home. • Ensuring that staff are appropriately trained to undertake the handling of medication safely and effectively. The home was using Medicine Administration Record (MAR) charts to keep a record of the current prescribed medication and of the compliance to take the medication for each resident. A review of the current charts showed that there had been improvements in the record keeping. Using the MAR charts the home was recording, with the exception of the handwritten entries, the receipt of the medication received by the home. Where the home had recorded the receipt of the medication it was unfortunately that the home had not consolidated the quantity received with the quantity already present within the home. This meant therefore that it was impossible to audit the medication to see whether the MAR charts showed that the residents had received their medication as prescribed. The registered manager was asked to ensure that all medication received was recorded and any quantity of medication remaining from the previous month was carried over into the new month. The MAR charts showed no gaps, the use of abbreviations to signify none administration was being done to good effect and the handwritten entries were mirroring the information displayed on the dispensing labels. Another issue identified was that some medication had been prescribed with variable doses and it was seen that the home had no record of what circumstances would result in the higher doses being given and visa versa. The home was also not recording which particular dose was given on the MAR charts. The home had obtained authorisation for the use of the homely remedies described in their protocol from the GP of each resident living at the home. On observing the container that held the homely remedies products it was seen that Covonia syrup, Zantac tablets and Gaviscon liquid were present. These three items were not listed on the homely remedies protocol for the home and therefore the home was asked to remove them from use. With the introduction of the Boots Monitored Dosage System (MDS) and the use of the mobile drugs trolley there had been significant improvements in the administration of the residents medication. The staff were administering all of Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 13 the residents medication from properly labelled containers. One of the residents who was receiving Alendronic acid was spoken to by the inspector and it was determined that the home was now administering this medication as specified by the manufacturers. Those residents who were self administering part of their prescribed medication had been risk assessed by the home and one of the residents had been persuaded to allow the staff to take control of his medication. On observing the risk assessment forms it was found that there was not enough detail to substantiate the homes decision to support the residents in their wish to self medicate. The home was asked to repeat the risk assessments for the residents wishing to self administer their medication to examine and demonstrate in greater detail the risks involved for each resident. The Pharmacist Inspector was shown assessments that had been undertaken by the Manager to ascertain that the staff who were administering the medication to the residents were competent to do so. The storage and organisation of the residents’ medication was much improved. The home was using two mobile drug trolleys to store the residents’ medication in. One of the trolleys was used to store the current medication and the other to store the excess stock. Both trolleys had been organised so that each of the resident’s medication was being kept separate from the other residents’ medication. The level of stock was at an acceptable level and the external medication was being stored separately away from the internal medication. The temperature of the fridge was now being monitored on a daily basis using a maximum and minimum thermometer. Unfortunately the home was not maintaining the fridge within the correct temperature range of between 2 and 8°C. The home was also reminded that the currently used Xalatan eye drops should be kept at room temperature for a period of 28 days rather than in the fridge. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP, 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of the home are planned around the residents’ needs and wishes. Staff listen to service users and make considerable effort to provide a flexible service, which enables them to enjoy a better quality of life. EVIDENCE: The manager informed of the recruitment of a social activities coordinator. A monthly programme of activities is arranged and a leaflet is produced with the information, a copy is displayed on the notice board at the entrance to the home. Service users and relatives spoken with discussed the frequency and content of the activities arranged and confirmed that they were satisfied with what is arranged. One service user spoken with explained that they preferred to stay in their own room and had ‘plenty to do…. Jigsaws, DVD’s and CD’s’. They also spoke of a recent visit to the local shops and was able to purchase some fresh fruit. Three on site surveys, completed by service users, staff and relatives, made comments in the ‘what do you think could be done better’ section of ‘ perhaps Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 15 more time to be spent with the residents’, ‘ little more time with the residents’, ‘ more frequent checks on residents by staff’. People visiting the home during the inspection confirmed that they are able to visit at times suitable to their relative and friend and that they always felt welcome to visit. During the tour of the premises many of the bedrooms were highly individualised with personal possessions. Staff were observed to be offering residents choices and preferences as to the activities of the day in an appropriate way, very much dependent on the capabilities and capacity of each individual. Five on site surveys indicated that the food had improved in the last six months. A four weekly rotational menu is operational and offers a good choice of meals on a daily basis. Records are maintained of the food offered to and taken by each individual. It was recommended to the cook that all records be kept for three years from the date of the last entry. The cook demonstrated a good knowledge of the personal preferences for the people in residence and confirmed that alternatives are available if required. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. Service users and others associated with the home demonstrate a good understanding of how to make a complaint and they are very clear of what can be expected to happen if a complaint is made. EVIDENCE: The home has a complaint procedure a copy is displayed on the notice board at the entrance to the home, it is also include in the statement of purpose. The Commission for Social Care Inspection received one complaint directly in November 2006; this concern was discussed directly with the complainant and staff at this inspection. The complainant is satisfied with the response offered by the home but the issue has not been completely resolved. Social workers and the advocacy service were involved. Complaints received at the home are logged and audited on a regular basis. The home has a procedure for the protection of vulnerable adults and a copy of the local multi agency adult protection procedures are available for staff reference if required. Staff confirmed their attendance with adult abuse awareness training; the home has purchased a training video for in-house use. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and homely environment that has benefited from a positive response to ‘Environment’ related requirements cited at the previous inspection. The gardens are easily accessible at all times of year. General cleanliness throughout the Home is good. EVIDENCE: A large proportion of the requirements cited at the previous inspection arose from shortfalls in the ‘Environment’ outcome area. Listed below is the action, taken in each instance by the home, so as to meet the related ‘Requirement’: The Manager sought advice from the Environmental Health Officer regarding the proximity, of the area designated as the area in which service users may smoke, to the main kitchen. A letter from the Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 18 Environmental Health Officer, dated 20/10/06, was seen which expressed no concern over the arrangement A tour of the home showed that: o Damaged bath seats and bath surfaces have been satisfactorily repaired o All hot water outlets to which service users have access are regularly tested to ensure temperature is at about the required temperature of 43o Celsius (records seen) o The alarm bell in the lifts are regularly tested (records seen) o Call bells are now accessible in all communal areas including bathrooms o A damaged mirror in one bedroom has been repaired o Lockable storage is available in all bedrooms o All bedroom doors are fitted with locks suited to service users capabilities o The Home was found to be odour free o Stained carpets have been replaced o Ambient temperature within the medicines room is monitored and recorded (and found to be within a satisfactory range) o Foot operated bins to receive clinical waste and infected linen are now provided in all areas where necessary o Hand washing facilities are available for staff at all points of care delivery e.g. all bedrooms The manager, staff, and owners have worked hard, and effectively, to meet all of the requirements relating to the above areas. To ensure this progress is maintained the home should have an ongoing redecoration/refurbishment plan. A number of commodes were observed in bedrooms for use at night, it is strongly recommended that automatic sluice/disinfectors are available for the safe disposal of bodily waste. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates a robust recruitment process for staff ensuring that the safety of service users is upheld. EVIDENCE: At the time of the inspection the manager was supported by an assistant deputy manager and two care staff, catering and domestic staff were additional. Staffing levels are reduced at night to two waking care staff. The manager explained the on call arrangements for additional staff in the event of an emergency arising. A rota is maintained to show which staff are on duty at any given time of the day or night. Staff spoken with confirmed that training in National Vocational Qualification Levels 2 and 3 in care is ongoing, the statement of purpose details the training accreditations awarded. Two staff personnel files were selected for inspection and contain all documents relating to a robust recruitment procedure. Certificates and records of achievement are retained to evidence the training undertaken by each individual. Each staff member has regular supervision with their line manager and an annual appraisal of their work performance. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are very clear lines of accountability within both the external and internal management structures and the management approach creates an open and positive atmosphere from which the service users benefit. EVIDENCE: The manager has continued to make progress with developing systems for the day-to-day management of the home. Staff, service users and visitors commented positively on the style of management. Through out the duration of the inspection the manager demonstrated a sound knowledge of the current resident group and the difficulties and dilemmas encountered with the ageing process. Training for accreditation on the Registered Managers Award is ongoing. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 21 Procedures of the monitoring of the service provision have been introduced on a weekly and monthly basis. Any comments or issued raised from these audits are passed on to the relevant departments for improvements to be made. The home offers a facility for service users to deposit personal monies for safekeeping; improvements have been made, the records relating to this are being maintained and fully receipted. Records are maintained, and evidence that the required health and safety checks are being carried out at regular intervals in relation to fire safety, hot water temperatures, portable appliance testing and chemical substances (COSHH). Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13(2) Requirement Timescale for action 01/03/07 2 OP9 13(2) 3 OP9 13(2) 4 OP9 13(2) The home must develop a comprehensive policy and procedures document for the handling of medication within the home, which depicts all of the procedures that are and need to be carried out by the Nursing staff. The quantities of all medication 01/03/07 received by the home must be recorded and confirmed with a signature of the member of staff receiving the medication Detailed risk assessments must 01/03/07 be carried out for those residents wishing to self medicate and the information recorded must be able to support the home’s decision to allow/refuse the residents’ wishes. The home must also establish a monitoring programme to ensure that these residents act in accordance with the prescribers’ directions. The temperature of the fridge 01/03/07 must be maintained at between 2 and 8°C. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP26 Good Practice Recommendations It is strongly recommended the home develop and maintain an ongoing redecoration/refurbishment plan. It is strongly recommended that consideration be given to the installation of automatic sluicing disinfectors, on each floor, for the safe disposal of bodily waste. Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Birkdale DS0000049825.V308503.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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