Inspection on 24/11/05 for Clarendon House

This inspection was carried out on 24th November 2005.

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

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

Other inspections for this house

Clarendon House 20/11/07

Clarendon House 09/05/06

Clarendon House 19/05/05

Clarendon House 09/03/05

Clarendon House 24/11/04

Clarendon House 26/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Clarendon House Carrwood Road Bramhall Stockport Cheshire SK7 3LR Lead Inspector Kathleen Mcall Announced Inspection 24th November 2005 10:15 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 Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Clarendon House Address Carrwood Road Bramhall Stockport Cheshire SK7 3LR 0161-488 4107 0161 488 4107 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) Davenport Manor Nursing Home Limited Paula Beckley Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 32 OP. Date of last inspection 19th May 2005 Brief Description of the Service: Clarendon House is a residential care home that is registered to provide accomodation for up to thirty two older people. It is one of two residential care homes owned by the Davenport Manor Nursing Group, the other being Davenport Manor residential care home. The registered providers are Kiran Patel and Mr Dilip Patel. The registered manager is Miss Paula Beckley, who has held the postion since November 2003. Clarendon House is a large Tudor Style residence that is situated on Carwood Road, Bramhall. The home is set back off the road with substantial gardens surrounding the property with access to Bramhall Park. There are no bus routes that run directly to the home. The nearest shops are situated on Bramhall Road or in Bramhall village, which is approximately a five minute drive away from the home. The home has twenty single rooms, ten of which have ensuite facilities and six double rooms which have no ensuite facilities. All rooms have a washbasin. There are two lounges and two dining rooms. There is a passenger lift to assist residents to their bedrooms on the first floor. The home is suitable for wheelchair users. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over the course of two days. A pharmacy inspector accompanied the inspector, and assessed the medication management and administration systems at the home. The registered manager accompanied the inspector throughout the inspection process. Care plans, assessment documentation, and several policies and procedures were examined. The inspector spoke with a number of residents, members of staff and spoke with a relative of a service user residing at the home. Seven service user comment cards were returned; six cards indicated that residents like living at the home and one responded that sometimes they liked living at the home. Six service users indicated that they liked the food and one did not provide an answer. Six cards indicated that service users felt safe living at the home and one did not provide an answer. Five comment cards indicated that residents knew who to talk to if they had a problem; one indicated that they did not know who to talk to and one did not provide an answer. Five cards indicated that residents felt well cared for living at Clarendon House, one said sometimes and one did not provide an answer. Four comment cards indicated that staff treated them well, two said sometimes and one did not answer. Two cards expressed a degree of dissatisfaction with the activities on offer and a number of residents told the inspector that they would like more activities to take place. One resident said there wasn’t enough going on in the home in terms of activities and another resident said she would like more variety. Six relatives comment cards were returned to the inspector; all cards indicated that relatives always felt welcome at the home. Five said that they were kept informed of important matters affecting their relative and one felt that they were not kept informed. Five comment cards indicated that if their relative was unable to make a decision they were consulted about care issues and one said they were not. Three cards said that there was not always sufficient staff on duty and three said that there was. One relative wrote ‘staff always cheerful, helpful and very caring’. Another wrote ‘without the staff this home would be average! The youngsters keep the residents amused – they have so much fun with them’. One relative wrote ‘The staff lack supervision from the management’. Two GP comment cards were returned. In response to questions ‘Does the home communicate clearly and work in partnership with you?’ and ‘Is there always a senior member of staff to confer with?’ one GP had answered no to both questions. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 6 A relative with whom the inspector spoke complained about levels of smoke from the staff smoke rooming affecting her mother’s bedroom on the lower ground level. This was discussed with the registered manager at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: At the previous inspection it was identified that care plans were poor and needed to be developed. At the time of this inspection it was observed there had been some improvement, however care plans still did not give a full picture of how the home was meeting a residents care needs. The standard of risk assessments had not improved since the last inspection and risk assessments still did not include those measures and strategies the home would be taking to reduce identified risks. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 7 A number of issues concerning medication storage and recording were noted on the inspection by the pharmacist inspector and the home has been issued with a number of requirements to address the problem. There have been ten complaints since the last inspection; a further complaint and an adult protection referral were made at the time of the inspection. The adult protection issue was dealt with in a separate letter to the registered providers. At the previous inspection the home was required to provide training in adult protection for care staff. At the time of this inspection only a small percentage of the staff group had received such training. A number of residents were unhappy with the level of activities provided and the registered manager has been asked to consult with residents about their preferred choices. 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. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Information was not always provided to prospective service users. Service users had been issued with a written contract and their care needs were fully assessed before admission. EVIDENCE: Since the last inspection the registered manager had updated the Statement of Purpose to include staff training and NVQ training. The Statement of Purpose said that the home has ‘an activities co-ordinator’ who ensures a varied programme is on offer.’ This was misleading information, as it was the practice of the home that organised activities were the responsibility of staff on duty rather than a specific member of staff. A service user recently admitted to the home told the inspector that she had not received any information in the form of a service user guide to assist her in her decision to move into the home and two other service users could not recall if they had received information or not. However the registered manager told the inspector that information was given to all prospective service users. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 10 Those service users recently admitted to the home had a written contract, which detailed the terms, and conditions of their stay as did long term service users. Service users recently admitted to the home had been assessed prior to their admission. Assessments were obtained from social workers and health professionals if they had been involved in the admission. Service users told the inspector that they were happy with the way in which the home was meeting their needs. One service user told the inspector that she had visited the home and had stayed for lunch before deciding to move in. Other service users were happy for their relatives to visit on their behalf. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Care plans did not accurately reflect how service users cares needs were being met. Medication practice was unsatisfactory. EVIDENCE: Since the last inspection the registered manager had reorganised service users files. All information concerning a service user was now stored in one accessible file, that included care plans, assessments, contracts, GP and district nursing notes and risk assessments. Staff reported that the new style of files were easier to work with. Care plans examined did not always accurately reflect the current needs of a service user; many had not been updated to reflect recent changes. The home used agency staff and thus it was important that accurate and up to date information was recorded on care plans. All staff recorded on care plans, the general standard of recordings were good and provided detailed information on how a service users needs had been met. However the inspector did observe a recording by a member of staff that contained critical information about a service user. The registered manager was not aware of this information. The registered manager did not routinely Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 12 check care plans, daily records, risk assessments and medication administration records to assess their quality. Risk assessments were completed for falls, the use of bed rails, wheelchairs and hoists and for those service users who wished to manage their medication. Risk assessments did not consider what actions were required to address an identified risk; they merely stated what the identified risk was. The registered manager was informed on a previous inspection that risk assessments needed to be developed and include strategies that would be put in place to reduce an identified risk. Risk assessments were reviewed on a regular basis however these did not indicate whether the risk continued and if any changes were required. Similarly care plans were reviewed on a monthly basis, but not all aspects of the care plan appeared to have been reviewed. One service user whose care plan stated that the use of a hoist was required for most moving and handling procedures had been ‘grab lifted’ on a number of occasions. The registered manager was advised that this was not an acceptable practice and the use of the hoist should be considered and that staff should update their moving and handling training to ensure that service users are not put at risk by inappropriate handling. A pharmacist inspector examined the storage and administration of medication at the home and made a number requirements and recommendations in terms of the homes practices. Service users told the inspector that staff treated them well and they were very satisfied with the care they received. Care staffs approach towards service users was observed to be respectful, sensitive and caring at all times. One relative felt that she was not always kept informed of matters affecting her relative. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The day-to-day routine of the home including mealtimes was relaxed and informal and met service users needs, however activities provided did not meet all service users expectations. Mealtime arrangements were well managed and satisfied service users expectations. EVIDENCE: The day-to-day routine of the home was relaxed and flexible with some service users preferring to spend time in their rooms and others using the lounge facilities. Service users told the inspector that they could get up and go to bed when they wanted that the day was theirs to spend how they choose to. The home had an activities programme that was flexible and changeable depending on what service users wanted to do. On the day of the inspection service users were having a game of skittles. Several service users’ expressed a level of dissatisfaction with the range of activities currently on offer at the home. A large number of service users told the inspector that they didn’t feel there was enough activities going on and several others felt that the level of activities was appropriate. Some service users were unhappy with the positioning of the TV in the top lounge as it meant that those service users sat at the top of the room were unable to see the television. One service user who said that she was unable to read but that she liked to watch TV and said that there was nothing else for her to do. One relatives comment card said ‘a Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 14 better TV with video/DVD would be a bonus – the old people spend all day in the lounge and the TV is small and has seen better days.’ The registered manager told the inspector that there were plans to install digital TV at the home. Visitors were made welcome at the home and service users kept in touch with family and friends. Service users confirmed that they could have visitors at all times. Meals were served at regular intervals and were usually taken in the dining room areas. The lunchtime meal was the main meal of the day and the teatime meal was lighter with a hot and cold option. Service users told the inspector that they had enjoyed their lunch and that the meals provided were very good and, that a wide choice was available. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Service users felt confident that their complaints would be taken seriously and acted upon. Adult protection procedures at the home were not robust enough to protect service users from abuse. EVIDENCE: There had been ten complaints since the last inspection; a further complaint and an adult protection referral were made at the time of the inspection. The adult protection issue was dealt with in a separate letter to the registered providers. Several service users told the inspector that they knew who to speak to should they have a complaint and that they felt confident that their complaint would be listened to and acted upon. Since the last inspection a small number of staff had completed training in adult protection, including the registered manager. The registered manager was unable to provide evidence of the course content. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 16 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, 21, 24 and 26. The home was well maintained and provided comfortable living accommodation for service users. EVIDENCE: At the time of the inspection the home was well maintained throughout and provided comfortable accommodation. The grounds of the home were well kept and attractive. The home was clean, tidy, bright and airy throughout and was free from any unpleasant odours. A number of service users rooms were seen, these were also furnished and equipped to a comfortable standard, many had been personalised by the occupants. Since the last inspection damaged ceilings in the home had been repaired. A walk in shower had been fitted and the home now provides enough assisted Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 17 bathing facilities to meet service users needs. The car park of the home had been resurfaced and a ramp had been fitted to the front of the building. Service users had been provided with individual laundry bags in an attempt to improve the laundry arrangements at the home. One relative with whom the inspector spoke said she was still experiencing some difficulties with items of clothing being lost. The registered manager was aware of these difficulties and hoped that individual service user laundry bags would ease the problems. Another relative wrote ‘I am very impressed with the new furniture in my mothers room but please can we have a coat of paint, new carpet and new curtains in the lounges, dining room and communal hall way – desperate!’. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 18 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 and 29. The home was sufficiently staffed and recruitment procedure ensured that service users were protected. EVIDENCE: At the time of the inspection the home was sufficiently staffed, a staff rota showing, which staff were on duty and in what capacity, was kept at the home. Since the last inspection the home has employed a number of domestic and laundry staff. One relative complained to the inspector about passive smoke from the staff room filtering into her mother’s bedroom. The inspector discussed this with the registered manager who agreed to look at the situation. One service user who preferred to spend time in her bedroom rather than use the communal areas of the home told the inspector that she would like care staff and the registered manager to call in and see her more frequently than was the practice. There were several service users who preffered to spend time in the their bedrooms. A number of service users spoke very warmly about the staff and comments on relatives comments cards included, ‘staff are great and always available if needed’, ‘staff always cheerful, helpful and very caring’, ‘very pleased with home, staff and food.’ Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 19 Since the last inspection four new members of staff had commenced employment at the home; the registered manager had followed appropriate recruitment procedures with regard to newly appointed staff. 75 of the current staff group held an NVQ qualification. Care staff on duty at the time of the inspection confirmed that they had undertaken further training to assist them in their role as carers these included moving and handling updates, food hygiene, drug awareness and health and safety training. However despite staff having completed training in moving and handling it was reported that staff were ‘grab lifting’ service users. The registered manager was advised that this practice was unacceptable. (See standards 8 and 38). Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35, 36 and 38. The registered manager did not manage the home in a competent manner and the health and safety of service users was not fully promoted. EVIDENCE: Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 21 Ms Beckley has been the registered manager at Clarendon House since November 2003 she holds an NVQ Level 4 qualification in management and care. One relative with whom the inspector spoke felt that the registered manager did not receive enough support from the registered providers to undertake the duties involved in being the registered manager of the home and that the management at the home was not proactive enough in bringing about changes. The registered providers visit the home every two weeks. Despite staff receiving regular supervision to support them with their work, the registered manager did not routinely assess the quality of care provided; care plans, daily records and medication at the home. As a result of the registered manager failing to take appropriate action, a number of issues concerning the practices at the home and those of the registered manager came up during the inspection. These issues have been dealt with in a separate letter to the registered providers. The home did not have clear lines of accountability between staff and management. Service users are encouraged to handle their own finances or with support from family or representatives. Small amounts of cash were kept for individual service users for day-to-day expenses ie. hairdressing costs. One relative complained that staff had assisted her relative to purchase items without consulting her and felt that her relative did not have the capacity to make such decisions. The home recorded information in respect of falls and accidents by service users. The home complied with the requirements of the fire authority. The home maintained records in respect of fire safety at the home. Staff had updated their training in safe moving and handling procedures, food hygiene and health and safety. There were concerns about care staffs moving and handling practices. One member of staff was training to be a moving and handling trained assessor. (See standards OP 8 and OP 28). Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 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 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 X X 2 3 X 2 Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 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 OP1 Regulation 4(2) Requirement The registered providers must ensure that all prospective service users and service users recently admitted to the home are given a copy of the service user guide. The registered providers must ensure that care plans illustrate how the service users needs in health and welfare are met. (Timescale of 19.08.5 and previous timescale of 24.01.05 not met.). The registered providers must develop risk assessment held in respect of service users, to include actions and measures taken to minimise the risk. (Timescale of 19.08.05 not met) The registered providers must ensure that appropriate moving and handling techniques are used by care staff when assisting service users and that staff are appropriately trained in moving and handling techniques. The registered person must ensure that on occasions where a variable dose of medication is DS0000008548.V271370.R01.S.doc Timescale for action 24/12/05 2. OP7 15 24/12/05 3. OP7 13 24/12/05 4. OP8 13(5) 24/11/05 5. OP9 13(2) 17(1)(a) 01/12/05 Clarendon House Version 5.0 Page 24 6. OP9 13(2) 17(1)(a) 7. OP9 13(2) 13(4)(c) 8. OP9 13(2) 13(4)(c) 9. OP9 13(2) 13(4)(c) 10. OP9 13(2) prescribed, for example, one or two tablets to be taken, an accurate record is made of the actual dosage of each medication administered. The registered person must ensure that if the dosage of medication is amended by the prescriber, the current record is discontinued and a new record is commenced. If the new record is handwritten it must be signed and dated and the details validated by an additional member of staff. The registered person must ensure that residents who wish to manage their own medication are assessed as to their ability to do so, before medication is provided to them. Assessments must then be repeated on a regular basis. The registered person must ensure that medication which requires refrigeration is stored in a secure refrigerator and is appropriately separated from food items. The temperature of the medicines refrigerator must be recorded daily on a maximum/minimum thermometer. The registered person must ensure that all items of medication which have exceeded their expiry dates, do not belong to current residents or are not labelled with prescribed directions are returned to the supplying pharmacy. The registered person must investigate the detailed discrepancies in the controlled drugs book and record the outcome on the appropriate page. (Timescale of 19.05.05 and 24.11.04 not met.) DS0000008548.V271370.R01.S.doc 22/12/05 22/12/05 19/01/06 01/12/05 19/01/06 Clarendon House Version 5.0 Page 25 11. OP12 16(2) 12. OP18 13(6) 13. OP18 Sch 3 14. OP31 12(1) 15. OP32 10(1) The registered person must consult with service users about their social interests and preferred programme of activities and provide this information for the next inspection. The registered person must make arrangements for all staff to attend training in Adult Protection. The registered person must ensure that all allegations and incidents of abuse are followed up promptly. (Timescale of 19.05.05 not met) The registered person must ensure that the manager, is provided with support and training to enable her to promote and make proper provision for the health and safety of service users living at the care home. The registered person must ensure that the care home is managed with sufficient care, competence and skill. 31/03/05 24/11/05 24/11/05 24/11/05 24/11/05 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 OP1 Good Practice Recommendations The registered providers should review information detailed in the Statement of Purpose in respect of an activities co-ordinator being in post at the home and clarify the position. The registered providers should ensure that the registered manager periodically reviews care plans, daily records, risk assessments and medication administration records held in respect of service users. The registered person should ensure that an accurate DS0000008548.V271370.R01.S.doc Version 5.0 Page 26 2 OP7 3 OP9 Clarendon House 4 5 6 7 8 OP9 OP9 OP9 OP22 OP35 dated record is maintained of all medication received or disposed of by the home. The registered person should ensure that stocks of medication are rotated regularly. The registered person should ensure that medication storage areas are used solely for the storage of medication. The registered person should ensure that the competency of carers with responsibility for medication administration is assessed regularly on a formal basis. The registered person should consider providing grab rail to assist service users when mobilising in the basement area of the home. The registered person should take into account service users choice and capacity to make choices when making decisions about service users monies. Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Clarendon House DS0000008548.V271370.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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