Inspection on 24/07/06 for Coppice Wood Lodge

This inspection was carried out on 24th July 2006.

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

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

Other inspections for this house

Coppice Wood Lodge 05/09/07

Coppice Wood Lodge 21/02/06

Coppice Wood Lodge 21/06/05

Coppice Wood Lodge 20/12/04

Coppice Wood Lodge 01/06/04

Similar services:

Clovelly House Residential Home Ltd

Cherry Orchard Nursing Home

Coppermill Care Centre

Fountains Care Centre (The)

Eleanor Palmer Trust Home

Elmstead House

Bridgeside Lodge Care Centre

Dalemead

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

CARE HOMES FOR OLDER PEOPLE Coppice Wood Lodge 10 Grove Road London N11 1LX Lead Inspector Wendy Heal Key Unannounced Inspection 24th July 2006 10:30 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 Coppice Wood Lodge DS0000030826.V301115.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. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coppice Wood Lodge Address 10 Grove Road London N11 1LX 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) 020 8366 6565 London Borough of Enfield Mrs Catherine Gallagher Care Home 44 Category(ies) of Dementia - over 65 years of age (44) registration, with number of places Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specified service user who is under 65 years of age and has Alzheimer’s may be accommodated in the home. The home must advise the regulating authority at such times as the specified service user attains 65 years of age or vacates the home. 21st February 2006 Date of last inspection Brief Description of the Service: Coppice Wood Lodge is a purpose built local authority care home. The home is owned and managed by the London Borough of Enfield and is located within approximately five minutes walking distance from the Arnos Grove Underground on the Piccadilly line. Bus stops and local shops are also within a short walking distance from the home. The home is registered for up to fortyfour older people who may have dementia. However, as part of a plan to make all bedrooms single occupancy, currently the home can accommodate thirtyseven people. The home is a two-storey property with a lift to all floors. Coppice Wood Lodge is divided into four units; each with a number of bedrooms linked to a lounge. One unit is on the ground floor and the other 3 are on the first floor. Two care staff are assigned to each of the units during late and early shifts. Three waking night staff and a sleeping-in senior member of staff covers the night shifts. There are a number of bathrooms, toilets and washing facilities throughout the home. The home is accessible for people with mobility difficulties. The homes most recent inspection is available on the homes notice board and the manager has agreed to put a copy of the homes purpose and function document on display for relatives and service users. The fees for the home are £641.00 per week. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place as part of the inspection programme. Compliance was checked against key standards and took approximately 8 hours. The inspector undertook a tour of the building and spoke with service users and members of the staff team. The inspector gained further information by an inspection of the documentation kept in the home, including care plans and health and safety documentation. Members of the senior management team assisted the inspector throughout the day. The inspector would like to thank the service users present during the inspection, the manager’s staff and service users for their openness and participation. What the service does well: What has improved since the last inspection? What they could do better: Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 6 The home must ensure that all risk assessments are kept up-to-date and contain detailed and accurate information relating to service users needs. The risk assessments must show consultation with service users or their relatives where appropriate, which will ensure service users needs are met. The home must ensure that all medication administered to service users is clearly recorded on the medication administration record. The home must ensure that there are records maintained of service users’ wishes and decisions regarding activities. The home must ensure that doors are not wedged open and the Emergency Fire and Planning authority are consulted in relation to magnetic door closures being fitted on those doors which are wedged open and therefore do not protect service users and staff in the event of fire. The home must ensure that checks are carried out on the homes water tanks to minimise the risk of legionella, which will protect the health and safety of service users and staff. 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. Coppice Wood Lodge DS0000030826.V301115.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 Coppice Wood Lodge DS0000030826.V301115.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): 1,2,3, 4,5 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Service users are given the information they need to make an informed choice about whether the service is suitable for them and their needs. The service adequately assesses individual service users needs and aspirations, which means that service users needs are more likely to be met. Prospective service users have the opportunity to visit the home prior to admission to see if it is suitable for them. Service users have an individual contract of terms and conditions, which means they know what the expectations are for them and vice versa. EVIDENCE: The home has a Purpose and Function Document, which could not be located on the day of the inspection, and a copy of this is going to be supplied to the inspector for examination. The service has a service user guide. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 9 Four-service user files were inspected all contained a range of clear assessment information relating to the time of the service users admission. The referring authority and health professionals had undertaken these assessments. There was also evidence that the home had carried out its own assessment at the point of admission with service users needs being reviewed on a regular basis to ensure that their changing needs can continue to be met. It was clear from evidence seen at the home that service users have the opportunity to visit the home to see the facilities available and to meet the staff that work at the home and the people that live there to enable them to make an informed choice as to whether it is were they would like to live. One relative who wrote to the inspector commented, “I was always made to feel welcome each time I appeared I never felt I was in the way.” The homes Service User Agreement clearly specifies the terms and conditions of the home. The Service User Agreement contains the details of the notice period which means that service users what the expectations are for them and vice versa. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Service users needs and aspirations are clearly set out in their care plans to ensure service users needs are consistently met. One service users risk assessment did not contain accurate information relating to the service users needs and would result in inconsistent levels of care for that particular service user. Service users health care needs are well monitored and service users are supported in addressing these with relevant health professionals. Service users are not fully protected by the homes recording of medication administered to service users. Service users receive sensitive support with their personal care from staff and are treated with respect and their wishes in the event of their death are respected. EVIDENCE: Four service user plans were inspected and were clear and up-to-date. The format of the care plan showed each identified assessed need or aspiration, and the desired outcome of these and guidance to staff on how to achieve the Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 11 outcome. The care plans were being reviewed by the home on a monthly basis, which ensures service users changing needs can be met. A range of risk assessments informed the care plans. Examples of identified risks included, mobility, the physical environment, prevention of pressure sores, and a history or risk of falls. One identified service users risk assessment needed to be updated and were appropriate show consultation with service users and their relatives. This assessment states that the service user wanders but this information was not included in the service users care plan, the manager stated this was because this was no longer the case and the service users needs had changed. This information was clearly contradictory and would result in inconsistent levels of care to the service user. A requirement has been made in relation to this. From discussions with the senior staff present on the day of the inspection and examination of the homes records were satisfactory. Evidence was seen that service users were supported to access health care through the National Health Service. Service users have access to GP’s Opticians and chiropodists and have access to the community dentist, which ensures that their health care needs are monitored. A visiting District Nurse confirmed that she had visited the home regularly to access and provide medical care to service users. A service users relative visiting the home expressed their satisfaction with the care provided by the home and said, ”I could not ask for better”. The home has a suitable medication policy and procedures and staff had received training to ensure that service users are protected by the homes medication procedures. The medication for service users was inspected with the relevant administration records. The MAR sheets had not been appropriately signed for one identified service user, which does not safeguard the health wellbeing and safety of service users. A requirement has been made in relation to this. At the time of the inspection the temperature of the medication cupboard was found to be satisfactory and did not exceed 25° degrees Celsius. The majority of service users needed prompting or physical assistance with tasks such as washing their hair. Service users spoken with indicated that the way they received support was sensitive and met their needs. During the inspection staff were observed interacting with service users in a friendly and respectful manner. The inspector received a letter from a relative of a service user who had passed away. They confirmed they were happy with the home. The relative stated, “The staff at Coppice Wood Lodge set an unexpectedly high standard of care and comfort.” Service users wishes in the event of their death had been recorded which shows that their individual rights and wishes are respected in the event of their death. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 12 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): 12,14,15, Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. The home provides a number of activities to meet service users needs. However, the inspector was not able to see a clear record of activities showing service users participation. The home supports service users to make as many decisions for themselves as they can to ensure they exercise choice and control over their lives. Coppice Wood Lodge serves varied and healthy meals that meet service users dietary needs. EVIDENCE: The senior staff on duty at the time of the inspection stated that the home welcomes visitors at reasonable times with the agreement of the service user. The times service users like to get up and go to bed are recorded in service users care plans along with their likes and dislikes which shows that service users have control over their lives and their preferences are taken into account. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 13 Discussions indicated that service users have a number of activities available including playing games like bingo, reading, watching television, going out for lunch, listening to music and there is a reminiscence group on a Wednesday and Friday which ensures they have access to activities within the home. Coppice wood has large gardens equipped with furniture were service users can relax or exercise. Coppice Wood Lodge does not have it’s own transport available, but accesses local community transport facilities. A programme of activities was not available or on display at the time of the inspection. The inspector was unable to see clear records on the current activities and the service users level of individual participation to show that their individual needs are being met. The home must maintain a clear record of service users wishes, decisions, and participation in activities. A requirement has been made in relation to this. Their families manage service users’ finances. However, the home receives personal allowances for each service user to pay for personal items and services such as visiting the hairdresser. It was confirmed that the service users’ personal allowances and the home’s petty cash are audited by the Council Auditors. It was clear from the inspector’s observations and discussions with service users and the staff that service users are consulted on matters affecting individual or collective needs through care planning meetings or service user meetings. The menu was inspected it showed a variety of nutritious meals. The service users spoken with stated they enjoyed the food at the home. One said with some enthusiasm “that the food was very tasty”. Service users spoken with also confirmed that the home would provide an alternative meal on request if they did not like what was being served on a particular day, which ensures that service users dietary needs are being met. The inspector observed that staff were present in the dining room to provide assistance to service users who needed help with eating their meal at lunchtime which was carried out in a sensitive manner and ensured that service users dignity was maintained. A number of service users suffer from diabetes and there was evidence that these service users received appropriate meals to meet their health needs. There was a variety of food stored in the home on the day of the inspection that was seen to be in date, appropriately stored and matched the menu which safeguards the service users health. Fridge and freezer temperatures were recorded daily and seen to be satisfactory which ensures that food is stored safely. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 14 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 area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Service users and their relatives can be confident that any concerns they raise in relation to the home will be effectively acted upon. Service users are protected by an up-to-date adult protection policy and procedures that staff were familiar with. EVIDENCE: The home has a satisfactory complaints policy that was clearly displayed in the home’s entrance hall for service users and visitors to see. The complaints policy included the contact details for the Commission for Social Care Inspection. No complaints had been made since the last inspection. The complaints were recorded in the same book as the incidents recorded in the home and were not recorded within a separate complaints section which it was agreed with the managers on duty is not the most effective recording system. A requirement has been made in relation to this. One relative spoken with at the time of the inspection confirmed that he had no concerns but indicated he could raise issues with the manager if he felt the need. The home has a satisfactory adult protection policy and procedure. Staff spoken to were familiar with the adult protection guidance and were able to give a satisfactory description of what abuse means and what actions to take Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 15 to protect older people from abuse. The home has a satisfactory whistle blowing policy. Staff files and discussions with the staff and the managers showed that staff had attended training on the protection of vulnerable people from abuse. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 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): 19,20,21,23,24,25,26. Quality in this outcome area is adequate. The judgement has been made from evidenced gathered both during and before the visit to the service. Service users live in a home that is adequately maintained making it a pleasant place to live. Service have access to safe and comfortable indoor and outdoor communal activities. Service users have access to an adequate number of toilets and bathrooms, which ensures their personal needs are met. Service users have individual bedrooms, which are personalised with their own items, which assists them to make the service their home. The home was clean and tidy throughout safeguarding the wellbeing of service users. EVIDENCE: The inspector carried out a tour of Coppice Wood Lodge, which is a purpose, built local authority care home. Coppice Wood Lodge is close to local amenities e.g. local shops. Coppice Wood Lodge is divided into four units with a number Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 17 of bedrooms linked to a lounge. The home is a two-storey building with a lift to all floors and is accessible to people with mobility difficulties, which ensures free access to all. One professional who works at the home commented that,” the home is always very clean and there was never any trace of bad odours”, which safeguards service users welfare and means that Coppice Wood Lodge is a pleasant place to live. The inspector observed that throughout the home, including the service user bedrooms, this was the case as all areas were clean, free from offensive odours and were all personalised by service users personal belongings. Appropriate facilities are provided to enable service users with a physical disability to access the garden and all parts of the home. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 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): 27,29,30, Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The home has a well – qualified stable staff team, in sufficient numbers, to support service users and to assist in meeting service users assessed needs. Service users are protected by the homes recruitment procedure. Staff were offered relevant training to further assist them in their own personal development and in meeting service users needs. EVIDENCE: Two care staff are allocated to work in each of the four units within the home. The home has a satisfactory staff rota. The staff on duty matched those identified on the rota, which means that there are adequate numbers of staff to meet the needs of service users. The number of service users living in the units varies depending on their individual needs. Care staff have a responsibility to carry out laundry tasks, which ensures service users appearance is safeguarded and their self-image is maintained. A sleep-in senior staff and three waking night staff cover night shifts to ensure service users needs are met. The staff are experienced committed and make up a stable staff team which means that service users needs are met by a consistent approach. The staff are well liked by people who live at the home and by the relatives. A relative who had written to the inspector stated, “the staff are dedicated and wonderful people” This relative also stated “there are Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 19 few more important jobs where it is so important to get it right-they get it right at Coppice Wood Lodge”. A number of staff files were inspected they showed evidence of an effective recruitment procedure and included evidence of two written references and satisfactory Criminal Records Bureau checks, proof of identity and a clear employment history which were in place for the staff employed at the home which ensures that service users are protected from abuse. A number of care staff employed at the home were in the process of undertaking their NVQ level 2 or level 3 which ensures that service users are supported by adequately trained staff. The inspector saw evidence of the staff induction programme carried out by the home, which ensures that staff are further, supported to carry out their duties. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36,38, Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. The home is run in the best interests of service users including safeguarding their financial interests from abuse. Staff were well supervised and this assists them with their own professional development and in meeting service users needs. The home does not have all health and safety procedures in place to protect service users and others that work and live in the home. EVIDENCE: The home’s procedures for monitoring service users’ expenses are satisfactory ensuring that all incoming and outgoing money is accounted for and audited regularly which protects service users from financial abuse. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 21 The inspector was pleased to see that the laundry and sluice room had paper towels and soap to wash their hands after handling infectious material. The home has installed hand-washing facilities in the sluice room to prevent possible cross infection, which protects service users and staff. The dust and rubbish had been cleared from behind the washing machines and is no longer a health and safety risk to service users as the risk of fire has been reduced. The homes extractor fans had been cleaned. However, the fan in the kitchen was dirty and the manager assured the inspector that this would be examined and cleaned. A number of doors were wedged open including the laundry room door and kitchen, which does not minimise the risk of a fire spreading in high-risk areas. A requirement has been made in relation to this. Evidence was seen of regular staff supervision and those staff spoken to confirmed that this was on a one to one basis in addition to any informal dayto-day supervision they received which ensures that a professional consistent approach is maintained in relation to service users. A range of health and safety documentation was seen including: the fire log that contained records of regular fire drills and fire point testing; fire alarm and fire equipment servicing; the home’s gas safety and electrical installation certificate. The inspector could not see evidence that the homes water system had been professionally inspected to assist to minimise the danger of legionella. A requirement has been made in relation to this. Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 3 X 2 Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 13 15 Requirement The registered person must ensure that risk assessments contain detailed and accurate information relating to service users needs. These must be detailed and show consultation with service users or their relatives where appropriate. The registered person must ensure that medication when administered to service users is accurately recorded on the homes medication administration record. The registered person must ensure that fire doors are not wedged open. The registered person must ensure that consultation with the emergency Fire and Planning Authority takes place to discuss the appropriateness of magnetic door closures being fitted on those doors which are regularly wedged open e.g. kitchen and laundry room. The registered person must ensure that records are maintained of service users’ DS0000030826.V301115.R01.S.doc Timescale for action 10/10/06 2. OP9 13 (2) 20/08/06 3. OP38 23(4) C 20/09/06 4. OP12 12 (3) 16(2) m n 20/08/06 Coppice Wood Lodge Version 5.2 Page 24 5. OP38 13(4) decisions and wishes regarding activities. The registered persons must ensure that that checks are carried out on water storage tanks to minimise the risk of legionella. 20/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Coppice Wood Lodge DS0000030826.V301115.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!