CARE HOMES FOR OLDER PEOPLE
Chapel Lodge 11 Hall Street Worsthorne Burnley Lancashire BB10 3NR Lead Inspector
Mr Jeff Pearson Unannounced Inspection 27th September 2007 09:45 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 Chapel Lodge DS0000009502.V343135.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. Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Chapel Lodge Address 11 Hall Street Worsthorne Burnley Lancashire BB10 3NR 01282 413901 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) Dr Zahid Mahmood Dabir Mrs Naila Dabir Mrs Julie Patricia Harrison Care Home 23 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (22) of places Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The registered provider should, at all times employ a suitably qualified manager who is registered with the Commission for Social Care Inspection. The home can accommodate 22 older persons and 1 older person with dementia DE(E) making a total of 23 residents. Date of last inspection Brief Description of the Service: Chapel Lodge is registered to accommodate up to 22 older people over the age of 65 and 1 person with dementia over 65. The home is a converted chapel with some bedrooms overlooking the cemetery. Chapel Lodge is in a residential area in the village of Worsthorne about two miles from Burnley town centre. There are some local facilities nearby such as a general store, post office, public houses and a Church quite close to the home. There is a small parking area to the front of the home, also gardens and a patio area. Garden furniture is provided. A ramp provides access to the front door. The home has inter-connecting sitting rooms and a dinning area. All the bedrooms are single; some have en-suite toilets. Staff are available to provide assistance with personal care and support. The home can provide for recreational activities. The registered providers live next door to the home. At the time of the inspection visit, the range of fees charged were between £332 and £374 per week, there were additional charges of £25 per week for en-suite toilets, also variable amounts for hairdressing. Written information about the home was available in the entrance hallway. Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Chapel Lodge on the 27th September 2007. The visit took 7¼ hours and was carried out by one inspector. Prior to the site visit, the manager was asked to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures in the home. Some residents, relatives and health care professionals were invited to complete surveys, to tell the Commission what they think about the care service provide at Chapel Lodge. The files/records of two people using the service were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living at the home. Discussion took place with the residents, manager, staff, homeowner and a visiting relatives. Various documents, including policies, procedures and records were looked at. Some of the accommodation and facilities were viewed. At the time of this inspection visit there were 22 people living at the home, 3 were in hospital. What the service does well:
The home was being managed well, the owners and manager were keen to provide a good service at the home, they were proactive and positive about providing a good service. One relative wrote, “Chapel Lodge makes the residents feel like part of a family. It is a good home, the care staff are always friendly and helpful” The residents spoken with felt well cared for and arrangements were in place to help ensure their needs were met. On person said, “Things are fine, they really look after you, the staff are very good” another commented “The staff couldn’t be better, they treat me very well, we get the doctor anytime we need them” Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 6 Privacy needs were being maintained and the residents were being treated with dignity and respect. Residents said - “We can see people in our rooms we have locks on our doors, we can lock them if we want, they ask if we want a key” The residents’ were generally happy with the activities available and residents meetings were being held so people could get involved and be consulted. Daily routines were fairly relaxed so people could be flexible in how they spent their time. “They can be long days but we pass the time,” said one person. People were being encouraged as far as possible, to make their own decisions and choices about things which affected them. “ Yes we have meetings, they are good for airing views, they ask if things are okay with us” explained one resident. The catering arrangements were generally good, all the residents spoken with appreciated the food provided, they said “Everything is alright, food is as good as you could expect, nearly every day we get a choice at lunch and teatime” “Its grand, the food is very good” Staff training and development was high priority at Chapel Lodge. The residents appreciated the staff and relationships between everyone in the home were good. Residents said - “Every one is very kind” and “We are one big happy family” The arrangements for families and friends to keep in touch were very good One resident explained “We can have visitors anytime, they always give them a drink, which is a very nice gesture, its what you’d do at home” a relative wrote “I visit Chapel; Lodge on a regular basis. I often have lunch with dad and enjoy my homemade meal. The owners are hands on and very approachable” What has improved since the last inspection?
New dining chairs had been provided and lounge chairs had been recovered to enhance the comfort of people living at the home. The washbasin in the ground floor bathroom had been re sited to provide better access to the bath. Staff had been provide with personal hands sanitizers, plastic aprons were available to ensure more hygienic practices. The food for liquidised/soft diets was being blended separately, to provide a more appealing meal in terms of texture, flavour and appearance. Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 7 To make sure proper action is taken when dealing with abuse and protection matters, clearer details had been noted in the referral guidelines. To keep medication safe, a new lockable fridge had been obtained. Better practices were in place for dealing with medication leaving the home with residents. 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. Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 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 Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People were being assessed prior to moving into the home, to make sure their needs and wishes could be met. EVIDENCE: The manager explained the usual practice when people move into the home and the action taken in relation to an emergency admission, which had involved consultation with relatives and health care professionals. A written procedure provided guidance for dealing with the admission process. Records showed assessments had been carried out with residents to find out about their needs and abilities before moving into the home. Social services assessment information had been obtained as appropriate.
Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 10 The format used by the home for assessing people had been updated, various health and social care needs and abilities, personal preferences about daily living were being considered. Records showed the residents and their relatives had been involved with the assessment process. Some residents spoken with remembered being assessed before moving into the home, some also explained how relatives had visited the home on their behalf. People had been enabled to stay at the home on a short stay basis, prior to making a decision about becoming a permanent resident. One person explained, “Its okay here, I think I’m going to stay” Five residents completing surveys; indicated they received enough information about Chapel Lodge before moving in and that hey had received contracts of residence. At the time of the site visit Chapel Lodge did not provide intermediate care. Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Most health and personal care practices and procedures were effective in ensuring people’s needs are properly and sensitively met. EVIDENCE: Residents spoken with were satisfied with the care provided and felt their needs were known and being met, one said “The care is very good, they will do anything for you” Three residents surveys indicated they “always” receive the care and support they need, two that they “usually” did. Care plans seen included some good basic instructions for staff to follow to meet identified needs. But some details were not very specific, such as the actual needs and level of assistance with bathing. Nighttime needs had not been fully included. Care reviews were been carried out, staff spoken with explained how they spent time going through care plans with individual residents, where possible people had signed in agreement with their care plans. Good practice in
Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 12 relation to ‘person centred’ care planning, monitoring and reviews was discussed with the manager. Five surveys from residents indicated they “always” get the medical support they need; one indicated they “usually” did. There were good records of residents receiving attention from health care professionals, such as District Nurses and GPs. Health care matters, such as nutrition were being considered as part of the initial assessment process. Positive comments were received from two health care professionals, one wrote, “ All the staff are pleasant. When concerned about a patient they do not hesitate to get in touch with us”. Medication storage was seen to be satisfactory, a new lockable fridge had been obtained. Records and stock checked as part of ‘case tracking’ were mostly satisfactory, however, there were no individual protocols for ‘when required’ and ‘variable dose’ medication, which meant it was unclear when such items were to be given or offered. One hand written entry had not been signed and countersigned, the manager agreed to ensure this practice was introduced. There was evidence to indicate senior staff were had been shown how to provide support with blood sugar testing, it was advised that this training be updated at least annually when circumstances change. There was no specific system in place to check medication processes and procedures, which would help ensure good and safe practise. Residents spoken with considered they were treated with dignity and respect. It was apparent people were being supported to take care of their appearance. A system was in place which linked residents to a named member of staff, who was responsible for overseeing aspects of their care. There was a telephone with a mobile handset, so people could make/receive calls in the privacy of their rooms. Observations of care practices indicated peoples’ privacy needs were being respected, for example, people were supported to see their GP’s in private. Staff were seen to speak respectfully to people, they explained how they promote privacy by knocking on bedroom and toilet doors. Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 13 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): 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. People living at Chapel Lodge had flexible lifestyles, opportunities to make choices and decisions, positive relationships were encouraged. EVIDENCE: Residents meetings had been held, which provided opportunity for discussion and consultation about happenings in the home, “Yes they have meetings I have been to one so far” explained one person. Records of the last meeting held in July showed various matters had been raised and discussed. The residents spoken with said, they could go to their rooms when they wished and that they could choose when they went to bed and got up in the mornings. “We can get up and go to bed when we want” said one person “We can sit outside if we want,” explained another. Most people were happy with the activities on offer, which included dominoes, bingo and film afternoons. A notice board showed forthcoming events, such as
Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 14 a “fit for fun” session. Seasonal events were being celebrated; photos were on display of previous years Halloween party. “ We get made a fuss off on or birthday,” said one resident. A trip to Blackpool was being considered. A trolley seen stacked with games jigsaws and other activities for people to partake in. People were being involved with daily living in the home; for example, one resident went out with a member of staff to collect the morning papers. Some people said there wasn’t much to do, it was therefore suggested further consideration be given to providing more suitable activities and pass times, for less able people. Care plans needed to take full account of peoples’ social needs, spiritual needs and relationships, so better attention is given to individual needs and preferences. Visiting arrangements specified in the homes guide, residents spoken with said they could see visitors at any time and in their own rooms. Visitors were being made welcome at the home, refreshments were always offered and people could stay for meals if they wished. Residents said a local Church group made regular visits to home. The residents meetings and the care planning process enabled people to make group and individual choices. Some people were handling their own monies others were being supported by their families. The residents had brought with them personal items such as ornaments, televisions, radios and small items of furniture. All residents spoken with expressed an appreciation of the food provided at Chapel Lodge. The days’ choice menu was on display in dining area and individual menu sheets were being used to record peoples’ choices. Records showed that on occasion people were not being routinely offered choices; this matter was discussed with the manager. Specific diets such as diabetic were being catered for and liquefied meals were being appropriately prepared. Lively discussion observed at lunchtime, people were seen to be supported to take their time and enjoy their meal as a social occasion. The dining area provided a pleasant environment; tables were set with place mats, table clothes and flowers. The record of meals served was not always being completed therefore diet intake was not being properly noted. Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 15 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): 16,18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Practices and procedures were effective in responding to complaints and providing safeguards for people using the service. EVIDENCE: Most of the residents spoken with were aware of the complaints procedure and how to express any concerns; one said, “ I would tell staff if I wasn’t happy, they would sort it out” relative surveys indicated that they had no concerns about the home. None of the residents raised any complaints about practices at the home. The complaints procedure was included in the homes guide and displayed in each persons room. A system was in place to record and deal with any complaints made. Responding appropriately to complaints, including investigation strategies and recording systems was discussed with the manager. Residents spoken with said they felt safe living at Chapel Lodge. The manager expressed an awareness of the action to be taken in relation to safeguarding people. Staff spoken with also had an understanding of protection issues and the procedures for reporting concerns. The protection from abuse policies provided information on signs and indicators of abuse, procedures for referring matters to the appropriate agencies were available, it was advised these be
Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 16 defined as step by step instructions, to provide clear guidance on the action to be taken in response to allegations, incidents or suspicions of abuse or neglect. Staff had received training on protection of vulnerable adults. Chapel Lodge DS0000009502.V343135.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): 19,26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provided comfortable, clean and attractive accommodation for the residents. EVIDENCE: The home was found to be very clean and free from unpleasant odours. All the residents spoken with expressed an appreciation of the accommodation provided at Chapel Lodge, including their bedrooms, which they had been encouraged to personalise. One said, “I love my bedroom” another explained “We have locks on our doors, we can lock them if we want, they ask if we want a key” The lounges, dining area and bedrooms were pleasantly decorated and the quality of the furnishings, fixtures and fittings was good. New furniture had dining been provided and the chairs in the lounges had been reupholstered.
Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 18 The manager said the residents were being involved with any changes made in the home. Records were being kept of any maintence matters; these were being attended to as required. The washbasin in the ground floor bathroom had been re-sited to provide better access to the bath. The floor tiles in one of the ground floor toilets presented as a tripping hazard, Mrs Dabir, homeowner, agreed to ensure this matter was given attention. The laundry provided satisfactory equipment and facilities for washing clothing and other items. One of the washers was not working, but this matter was being attended to. The laundry had infection control procedures displayed for staff reference. Staff had been provide with personal hands sanitizers, plastic aprons were available. Liquid soap and paper towels were available in the laundry and toilets; arrangements were being made to provide paper towel dispensers in all bedrooms. The grounds and gardens were well maintained and residents spoken with, said they had enjoyed sitting outside in better weather. Chapel Lodge DS0000009502.V343135.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): 27,28,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staffing arrangements and training, aimed to ensure the resident’s needs are effectively and safely met. EVIDENCE: The residents spoken with were very complimentary about the staff team. With comments made such as “we are well looked after” and “the staff couldn’t be better”. Relative surveys included very complimentary comments about the staff and manager. One wrote, “I am more than satisfied with Chapel Lodge. From the first visit I found the staff friendly and accommodating, from the owners to the manager and staff, we could not find any better” Staff spoken with considered, they had enough time to care for the residents. Staffing levels were sufficient for the numbers and needs of residents living at the home. However, it was advised staffing arrangements be kept under review, to ensure enough staff are available to effectively and safely support the residents, throughout the day and evening. The manager explained that staffing levels had been reviewed and that additional staff were to be recruited. Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 20 There was a low staff turnover at Chapel Lodge no new staff had been recruited since the last inspection, therefore staff recruitment records and practices were not assessed at this visit. A staff induction training programme with checklist was seen to be in place, the manager explained that any new unqualified staff would be supported to go straight on to NVQ (National Vocational Qualifications) level 2. Staff training and development was being given high priority at Chapel Lodge, the manager explained the arrangements made to link with a local Internet based training development partnership. The AQAA (Annual Quality Assurance Assessment) and discussion showed most of the care staff had attained NVQ level 2 and three were working towards this. Three staff had attained NVQ level 3. Arrangements had been made to ensure staff access the various training and updates, in matters such as first aid and infection control. Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Management and administration practices were effective in ensuring the home is run for the benefit of the residents, staff and visitors. EVIDENCE: This inspection showed the home has continued to improve due to the effective management practices. The manager had been at Chapel Lodge for five years, four as registered manager. She had attained NVQ levels 2,3 and 4 and the Registered Managers Award and was keeping up to date with all relevant training issues. The residents and staff made positive comments about the management of the home and one relative wrote, “I cannot praise Julie
Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 22 (manager) enough she never asks staff to do anything she would not do, the senior staff are of the same high standard” It was encouraging, that internet access had been obtained and consideration was being given to administrative support. Records of resident payments and charges were seen; good accountable systems were in place. The home was being re-assed for IIP (Investors In People) accreditation at the time of the inspection visit. The homeowners were making unannounced visits to the home and completing reports on their findings. Letters and cards of appreciation were seen from relatives, for the care and attention provided at Chapel Lodge. The manager said she recently had offered quality assurance surveys to the residents; families and visiting professionals were due to be given surveys. It was advised the information from surveys be collated in the AQAA (annual quality assurance assessment) Arrangements were in place for all staff to receive training in all safe working practice subjects. The homes AQAA completed by the manager indicated the servicing and checking of equipment and installations, fire drills had been carried out. Health and safety policies and procedures were in place; fire safety and environmental risk assessments had been carried out. Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 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 4 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 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 OP15 Regulation 17 (2) Requirement Records of the food provided for residents, must be in sufficient detail to show whether the diet is satisfactory (Timescale of 31/07/06 not met) Timescale for action 31/10/07 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 Care plans should be in sufficient detail to provide clear guidance to staff, of the actions to be taken, to meet the residents personal and social care needs. The care planning process should be developed to provide a more ‘person centred’ approach. Individual protocols should be written to provide clear agreed instructions for staff, on when to give ‘when required’ medication (Outstanding from last inspection) To promote safer practice, all hand written entries in medication records should be signed and countersigned as correct. A suitable auditing system should be introduced to ensure safe medication practices. 2. 3. 4. OP9 OP9 OP9 Chapel Lodge DS0000009502.V343135.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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