Inspection on 11/07/06 for Broadoak Grange

This inspection was carried out on 11th July 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Broadoak Grange 20/05/08

Broadoak Grange 05/07/07

Broadoak Grange 18/05/05

Broadoak Grange 03/02/05

Broadoak Grange 04/05/04

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 Broadoak Grange Sandy Lane Melton Mowbray Leicestershire LE13 0AN Lead Inspector Rajshree Mistry Key Unannounced Inspection 11th July 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 Broadoak Grange DS0000001648.V303160.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. Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadoak Grange Address Sandy Lane Melton Mowbray Leicestershire LE13 0AN 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) 01664 562008 01664 562008 Mr John Nunn Mrs Barbara Elsie Nunn Vacant Care Home 33 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (33), of places Physical disability over 65 years of age (10) Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling within Category PD(E) may be admitted to the Home when there are 10 persons of Category PD(E) already accommodated. Service User Numbers No person to be admitted to the home in categories MD(E) or DE(E) when 10 persons in total of these categories/combined categories are already accommodated within the home. 25th October 2005 Date of last inspection Brief Description of the Service: Broadoak Grange Care Home is one of 15 homes within the Broadoak Group of Care Homes, which was set up in 1986. The home is registered to provide care for 33 older people and is situated off Sandy Lane in Melton Mowbray. Public transport is nearby, with local shops a short distance from the home. There is a large car park for visitors. The bedrooms are on two floors, which is accessible by the passenger lift or the stairs. There is a mature garden to the rear of the home with garden furniture and a green house. The home’s brochure provides information about the service to prospective and current residents and includes the terms and conditions of the stay. The monthly fees range from a minimum of £269 to £379. People that live at the home are responsible for any additional charges such as private chiropodist, toiletries, hairdressing and newspapers. The CSCI published inspection reports are available at the home and referred to in the home’s brochure. The people who live there are informed of the CSCI inspection individually and anticipated through the ‘Residents and Relative Meetings’. Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this service consisted of pre-planning work undertaken prior to the visit to the home. This consisted of reviewing the completed preinspection questionnaire submitted to CSCI and review of the events that have taken place at the service since the last inspection. This was followed by the site visit on the 11th July 2006 that lasted over 7 hours. The primary method of inspecting was ‘case tracking’ the care of four residents living in the home. The inspection consisted of the Inspector looking at the care provided to four residents living at the home by talking to the residents themselves; talking with the staff supporting their care; checking records relating to their health and welfare; viewing their personal accommodation (with their consent) as well as communal living areas. The Inspector made observations of the care practices and the interaction between the staff and the residents. During the inspection observations were made of how the staff implemented the homes procedures. There was opportunity to speak with staff, visiting relatives and the Community Nurse. The Inspectors also checked other issues relating to the running of the home including health and safety and management and staffing areas. The findings from the inspection were shared with the Acting Manager at the end of the visit. Comments received from the residents have been incorporated into this inspection report. The Commission for Social Care Inspection is inspecting Broadoak Grange Residential Home against the Care Standards Act 2000. What the service does well: What has improved since the last inspection? Since the last inspection the requirements and good practice recommendations identified have been addressed with systems, procedures and protocols. In addition the service has carried out the following improvements: • Appointment of a Senior Carer and three carers; • Re-decoration and painting of the communal areas, dining room, corridors, and residents’ bedrooms; Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 6 • • • • • Introduction of soft and gentle music being played throughout the home; New garden / patio furniture for the residents. Changes to the staff shift patterns to reduce the need to find emergency staff cover; New uniforms for staff to identify their designation, i.e. carers and ancillary staff; Photo and name badges for all staff to wear whilst on duty. 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. Broadoak Grange DS0000001648.V303160.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 Broadoak Grange DS0000001648.V303160.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the site. Residents’ needs are assessed prior to moving into the home to ensure their needs can be met. EVIDENCE: The admission procedure was viewed in relation to four the residents tracked, including a new resident. All the resident have a contract, copy of the assessment including the social worker’s assessment and care plan to support the referral process. All four residents files viewed, detailed the specific care needs of the residents that would be met by the carers. Additionally information relating to the residents medication, history of falls, mobility, diet, known communication and mental wellbeing and social, religious and cultural needs. Residents spoken with informed that Inspector that relatives visited the home on their behalf, to be satisfied that their care needs would be met and the home was the right for them. Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 9 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, 9, 10. Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the site. The residents are well cared for having their health and social care needs met that promotes and maintains their independence. EVIDENCE: The Inspector spoke to the four residents tracked including a new resident recently moved to the home. All confirmed that their views are sought and how their individual care needs can be met. The care plans viewed clearly showed how the residents’ care needs should be met with consideration and preferences in the way care is provided, diet, medication, observance of religious practice, reference to any impairments and health care support provided by the District Nurse. For example one resident stated she has only the sight of one eye and restricted movement to the right arm, which was stated in her care plan. All residents indicated that they have identified keyworkers. The Acting Manager stated significant work has taken place to improve care plans to make them more ‘person centred’. Residents spoken with stated that their care needs were being met in a way that suited them and felt they were treated them with respect and dignity. Carers were observed speaking to this resident by standing in front and face-to-face, speaking clearly Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 10 and patiently allowing the resident to respond. The daily records viewed for the residents primarily indicated the intake of meals and drinks and whether they slept well. Records detailed the visits made by the GP’s and District Nurses, detailed any treatment and/or advice given. The daily records did not show how the residents were mentally stimulated the activities residents engaged in, receiving visitors, talking with the staff, singing or having the newspaper read to them. This was shared with the Acting Manager who accepted the records did not show how residents’ wellbeing and independence was met and reflected any changes. It was recommended that the recording practice is reviewed to and maintained, especially for residents who were unable to express or recall how their care needs were met. Observation during the inspection showed that carers have a good awareness of individual residents’ ability and showed respect in the way they spoke and assisted the residents. Carers spoken with described how they assist residents to maintain as much independence as possible, whilst maintaining their dignity. Medication is stored in a locked room and administered by trained staff. The Inspector viewed the medication for four residents tracked, which were in good order and auditable. However, there was a signature missing for one resident who confirmed she had received medication in the morning and a further anomaly regarding an instruction received from the GP to stop a resident’s medication was not dated. These issues were brought to the attention of the Acting Manager and rectified after double-checking with the resident. Fridge temperatures are being recorded daily. Residents spoken with indicated they receive their medication on time. The Inspector spoke with the visiting Community Nurse who stated training has been provided to the staff on ‘pressure area care’ and diabetes care training is to be confirmed. Comments received included “the home has improved recently, a lot nicer; resident do look well and always well presented. Prefer to see residents in their own rooms, privacy and comfort mainly, especially when changing dressing or taking blood samples”; “ staff are very good, . . . . . follows instructions given and would contact me if he had any concerns about the residents”. Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 11 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): 12, 13, 14, 15. Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the site. The residents continue to make choices about their daily living and are offered good choice of meals. EVIDENCE: There is gentle music being played throughout the home, which is enjoyed by the residents, especially during meal times. Residents are encouraged to enjoy social and leisure activities that suit them. The residents spoken with told the Inspector appeared to be fewer activities, such as Bingo with prizes. One resident told the Inspector she enjoyed watching the tennis in her own bedroom and preferred her own company. During the afternoon, residents were seen having a sing-a-long with a carer. Residents moved freely around the home. The smoking lounge/dining room is available to residents who smoke. One resident was observed choosing to sit on the benches outside. A carer was seen bringing out a cushion to make the resident more comfortable and positioning the parasol to provide some shade. Carers spoken with told the Inspector how they individually entertain the residents, reading the newspaper or going for short walks around the home or in the area. There are carers who speak Polish and were, up to recently, caring for polish speaking residents. Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 12 Several residents were receiving visits from relatives and friends. Visiting relatives spoken with said they were happy with the activities that is available to the residents, many relatives often choosing to stay for lunch. A visiting relative commented about the care provided “very good; value for money and feel my husband is cared for here”. Residents can continue to observe their religious beliefs although residents spoken preferred not to. Several residents had indicated their choice of breakfast, lunch and tea with ample drinks. The Inspector observed the hot meals being served at the dining tables, which are well presented. The chef told the Inspector he would speak to new residents to know what they like and any special diets required. At present one resident has been on a low-fat diet to improve his health as a result of GP’s advice. One resident stated that her meals are cut up into small pieces, as she does not have the use of one hand. Comments received from other residents about the care in the home was very good, including “ . . . .’s very good, he bought us all an ice-cream and lollipops twice this fortnight”, and “ food’s very good, we had ice-cream and strawberry”. This was in relation to the warm weather recently. Carers were observed providing drinks more frequently to the residents throughout the day as it was becoming warmer. Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 13 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): 16, 18. Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the site. Residents are protected by the good complaints’ procedure and by staff in the adult protection procedures. EVIDENCE: There is a complaints policy in place. Information about how and who to complain, including the contact details of the advocacy agencies are displayed on the notice board at the entrance to the home. No complaints received by the home since the last inspection. One complaint was received by the CSCI, which was referred to the Registered Person to investigate and was addressed appropriately. The Inspector also examined the supporting evidence in relation to the complaint, held in the office. Residents and a visitor spoken with had no concerns about making a complaint if the need arose and were confident that it would be dealt with correctly. Residents indicated that they felt safe in the home with the other residents and staff. Comments received included “aware of how to complain, I’ve got a brain, would tell . . . . . or . . . . or my daughter”. The home has a policy for ‘whistle blowing’ and safeguarding adults. Staff spoken with, were aware of the policy and fully understood how to report an incident. The home has a copy of the multi-agency procedure that has been incorporated into the home’s policy. Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 14 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): 19, 26. Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the site. The residents’ benefit from having a clean, well-maintained and personalised accommodation that suits their lifestyle. EVIDENCE: The home was clean, fresh, tidy and bright on the day of the inspection. Designated team of ancillary staff are responsible for the residents’ laundry, the cleanliness and hygiene of the home. The residents have a choice of lounges including a smoking lounge to relax in. The dining tables are set and small vases of flowers. The Inspector was invited to view two residents’ bedrooms both were individual in character and made homely with photographs and ornaments. One resident had vases of flowers, which were received on her 93rd birthday, celebrated recently. All but two bedrooms have en-suite facilities, although the toilet and bathroom facilities are nearby. Since the last inspection areas identified in need of attention have been addressed. The home has also undergone a programme of re-decoration and Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 15 painting in the dining room, corridors, communal areas and residents’ bedrooms. New garden furniture has been provided for the residents, including parasols. The Inspector observed the domestic staff storing securely cleaning products in accordance with the COSHH regulations. During the inspection of the home, staff were observed wearing different colour gloves and aprons depending on serving meals or assisting with personal care. Comments received from one resident, “my rooms beautiful, I call it the Queens Palace” and with reference to a special bath the resident stated, “carers are very sensitive, especially with bathing, using the space ship”. The comment received from the Community Nurse “home surrounding has improved, a lot cleaner and very rare to have odours and smells”, and “ the painting and décor is better – it’s much brighter” Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 16 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, 28, 29, 30. Quality in this outcome is good. This judgement has been made using the available evidence including a visit to the site. Residents are generally protected by the home’s recruitment procedure and with sufficient numbers of staff on duty. EVIDENCE: On the day of the inspection, the carers and ancillary staff were on duty as indicated by the staff rota viewed. Since the last inspection, an additional three carers and a Senior Carer have been appointed. Six carers have NVQ level 2, which is equivalent to 42.5 of the staff team. The two staff currently qualified first aiders’ within the home and at least one first aider is on duty at all times. The home’s recruitment procedure is good with the support from the Registered Person. The Inspector examined five carer’s personnel files, including the concerns raised about a member of staff. The files contained the application form, pre-employment checks such as references, confirmation of the Criminal Records Bureau (CRB) clearances, employment details and some evidence of training undertaken. The carers spoken with described the induction training undertaken, which included the home’s policies, procedures, adult protection, health and safety, food hygiene and a period of shadowing a senior carer. The carer showed an awareness of the residents’ care needs, how to support and assist residents to maintain and continue living independently. The carer stated that the Acting Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 17 Manager has arranged extra English classes for carers whose first language is not English. The Inspector spoke with the newly appointed Senior Carer and viewed the personnel file. Only one carer’s file showed they had received induction training. These concerns were discussed with the Acting Manager, who acknowledged the concerns and gave assurances to review the induction training procedure and records. The Acting Manager agreed to ensure all staff receive induction training and is documented to demonstrate that they have received the appropriate training to carryout their duties safely. Residents, visiting relatives and the Community Nurse spoken with felt the staff were very good, helpful and aware of their duties. All staff have uniforms to help residents identify the carers from the ancillary staff and are provided with ample protective clothing. Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 18 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): 31, 33, 35, 38. Quality in this outcome is adequate. This judgement has been made using the available evidence including a visit to the site. Residents’ and staff’s health, safety and welfare could be protected more by improvements in staff following procedures for reporting and recording. EVIDENCE: The home currently has an Acting Manager in post overseeing the day-to-day management and care of the residents living in the home. The Acting Manager manages the staff team with the support of the Senior Carer, although needs to consider establishing clear roles and responsibilities. The Acting Manager has demonstrated that a positive approach to ensuring the residents needs are being met safely by competent staff. The Acting Manager is considering making an application to be the Registered by CSCI, to manage this home but has experience of managing a health service, caring for older people. The staff, residents and a visitor spoken with said that he was very approachable and would listen to them. The Acting Manager is managed and supported by the Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 19 Registered Person who carries out monthly visits. Records of the monthly visits are held in the office, although none have been sent to the CSCI under the Regulation 26 notices. This was shared with the Acting Manager who agreed to share this with the Registered Person. Residents and their relatives spoken with confirmed they are consulted about the care they receive. At present there are no ‘Residents Meetings’ being held although there are plans are in place to have ‘Residents & Relatives Meetings’. Residents spoken with confirmed that have keys to their bedrooms and also a lockable cabinet to store valuables and money. The residents confirmed they manage their own financial affairs with the support of their family and other resident spoken with indicated if they wanted their money to pay for newspapers, hairdresser or go shopping they usually get the money immediately and sign for it. Resident finance records examined clearly showed financial reconciliation and management of the residents’ money, which is double-signed and auditable against the sums of money held on behalf of the resident. During the examination of the accident records, the Inspector pointed out to the Acting Manager the incomplete accident reports. The records demonstrated that staff were not fully aware of their responsibility in relation reporting accidents and incidents that affected the wellbeing of a resident. The Inspector also highlighted that no one was checking or following-up on the incidents and accidents that have been partly recorded. The Inspector also informed the Acting Manager that CSCI have not been notified of the significant events that has affected the wellbeing of the resident under Regulation 37. Records relating to health and safety procedures such as regular fire drills and fire alarm tests are completed and were up to date. Residents care files contained copies of the risk assessments carried out for mobility, use of walking aids and measure to control the spread of infection. It was recommended to the Acting Manager that risk assessments are dated to ensure the staff are aware of the most current assessment and is reflected in the measures to ensure the safety of all. Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 20 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 X X X X X 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 2 X 3 X 3 X X 1 Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO 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 OP38 Regulation 37 Requirement The Registered Person must ensure: (i) The accident and incident records are completed in full, and (ii) Timely submission of Regulation 37 notifications to CSCI, detailing the incident that affects the wellbeing of a resident. Timescale for action 11/07/06 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. Refer to Standard OP7 Good Practice Recommendations The Registered Person should ensure staff receive guidance and support to record in the daily care records the health and wellbeing of a resident to demonstrate how their needs are met. The Registered Person should ensure: (a) Medication records are signed promptly following the administration of medication, and DS0000001648.V303160.R01.S.doc Version 5.2 Page 22 2. OP10 Broadoak Grange 3. OP31 Instructions received from GP to stop medication for a named resident is recorded and dated, promptly. The Registered Provider ensures that monthly Regulation 26 visits carried out are submitted to CSCI on a timely basis. (b) Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Broadoak Grange DS0000001648.V303160.R01.S.doc Version 5.2 Page 24 - 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!