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Inspection on 23/01/06 for Cullum Welch Court

Also see our care home review for Cullum Welch Court for more information

This inspection was carried out on 23rd January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home was clean, tidy and well maintained to a high standard. Staffing levels were good and maintained above minimum levels. A wide variety of activities were provided and residents had access to the social events organised by the College. The grounds and gardens of the College were very well maintained and accessible to residents. Residents said the meals provided were very enjoyable and it was evident a varied and nutritious menu was available.

What has improved since the last inspection?

This was the first inspection of the home.

What the care home could do better:

Care plans must be prepared to show how assessed needs will be met on the ground floor. Staff on the first floor must understand the difference between assessment and care planning. Care must be taken when checking medicines brought into the home to ensure no errors had been made with the prescription. Receipt and record of medicines must be such as to enable an audit trail to be completed on them. The policies and procedures in relation to adult protection must reflect current legislation and practice. The information included in staff files must evidence staff were employed as required by regulation. Efforts must be made to implement the planned quality assurance system.

CARE HOMES FOR OLDER PEOPLE Cullum Welch Court Morden College 19 St Germans Place Blackheath London SE3 0PW Lead Inspector Ms Pauline Lambe Announced Inspection 23rd January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cullum Welch Court DS0000058195.V269904.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. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cullum Welch Court Address Morden College 19 St Germans Place Blackheath London SE3 0PW 020 8858 3365 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) Callum Welch Court Dawn Elizabeth Kenney Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This was the first inspection since the home was registered. Brief Description of the Service: Cullum Welch Court in a new care home built by the Trustees of Morden College on the site of the old home. The new home was registered to provide nursing care for 32 older people and personal care to 28 older people. The home forms part of the overall services provided by Morden College for its residents both on and off site. The home was built to a high standard and to comply with the requirements of the National Minimum Standards. Accommodation is provided on two floors with staff facilities on the third floor. All bedrooms are for single occupancy and have en-suite shower, hand basin and toilet facilities. Adequate communal, bathing and toilet facilities are provided and the home was decorated, fitted and furnished to a high standard. A pleasant and wellfitted hairdressing room was provided. The home is situated in the College grounds and is close to Blackheath Village with its shops and transport facilities. Residents have access to the College social club and other areas including the well-maintained and pleasant gardens. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the service and was completed by two inspectors over 8.25 hours. The manager was in charge of the home and staffing levels were assessed as adequate. The inspection included talking to residents, relatives, staff and management. Records required by regulation were inspected and a tour of the premises was undertaken. Residents seen were very positive about the quality of care provided and were satisfied with staff attitude and the environment. Staff were also positive about their employment and the management support and training they received. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be prepared to show how assessed needs will be met on the ground floor. Staff on the first floor must understand the difference between assessment and care planning. Care must be taken when checking medicines brought into the home to ensure no errors had been made with the prescription. Receipt and record of medicines must be such as to enable an audit trail to be completed on them. The policies and procedures in relation to adult protection must reflect current legislation and practice. The information included in staff files must evidence staff were employed as required by regulation. Efforts must be made to implement the planned quality assurance system. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 6 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. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 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 Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 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): 3, Standard 6 was not applicable. Pre admission assessments were completed for residents prior to admission. EVIDENCE: As part of registration the statement of purpose and service user guide were reviewed and complied with regulation. These were not reviewed at this inspection. Pre admission assessments were seen on resident files and these formed the basis of care plan development. Comprehensive information was obtained about resident’s health and personal care needs. This information was recorded on a pre printed form and was made available to staff. The majority of the current residents had been transferred back to the home from the temporary placements in two other homes while the new home was being built. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Individual care plans were prepared on the first but not the ground floor. Medicines were well managed on the first floor but improvements were needed on the ground floor. Residents were satisfied with how their needs were met and said staff treated them with respect. EVIDENCE: On the ground floor three care plans were viewed. These included long-term assessments of needs and some risk assessments. None of the files included a nutrition assessment and only one file had a care plan prepared to show how an identified need was to be met. The manager said the unit had introduced a new system of care planning and staff were learning how to complete these. On the first floor the standard of record keeping overall was good. However the records indicated that some staff did not fully understand the difference between assessments and planning process. Further training should be provided to address this issue. Short-term care plans and daily care records were detailed and provided good evidence about the standard of care provided in the home. Some care plans were not reviewed monthly which was identified as best practice in the National Minimum Standards for Older People. It was evident from the files seen that resident and relative views were sought and were used to develop personalised care plans where possible. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 10 Attention was given to ensuring the health needs of residents were being met. Access to community health care services was good and the arrangements for receiving medical attention were excellent. Residents could choose to remain with their existing GP or register with the GP from the local surgery. The college employed a GP, community nurses and a Physiotherapist to assess and treat residents and provide training for staff. A GP visited the home three times a week and nursing staff had access to medical information via a computer network. The G.P was in the home and told the inspector that in her opinion the home was well managed in relation to attention to resident’s health needs. Staff referred residents appropriately and followed advice given. Where necessary the GP discussed concerns with relatives on behalf of the resident. Resident’s were supported to access dental, optical, chiropody services and specialist services through GP referral. Systems were in place to record accidents to residents and records seen were well completed and accidents reported to other agencies as needed. The Physiotherapist completed audits on accidents and discussed findings with staff and the G.P. Policies and procedures and appropriate storage facilities were provided in relation to medicine management. On the ground floor a record was not kept for all medicines brought into the home. It was not possible to complete an audit trail, as it was not clear when new stocks were started. All entries were hand written onto the medicine charts but the information on the pharmacy label was not always copied accurately. Staff had access to information on medicines and a number of staff were completing a medicine course at Bromley College. On the first floor records of receipt and administration of medication were good. Staff on this floor had introduced new systems to ensure that all medication could be audited and accounted for. Storage facilities were good. One error had occurred when the pharmacist dispensed medication. This had not been identified by staff and had resulted in the resident receiving a lower than prescribed dose of medication. The sister said she would discuss the matter with the pharmacist and staff. The home had purchased equipment to de nature controlled drugs and had made suitable arrangements for the disposal of medication. All bedrooms were for single occupancy and bathroom and toilet doors had locks fitted. A number of residents said staff were very kind, caring and respectful and said they were satisfied with how their care was provided. Staff were courteous and polite when addressing and interacting with residents and relatives. Residents were appropriately dressed. Staff ensured that residents had access to a call bell and that all of their personal possessions were placed within their reach. Staff were observed knocking on residents doors before entering and spent time explaining procedures and reassuring anxious residents. Requirements 1 and 2 and recommendation 1. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Attention was given to ensuring residents had suitable activities, were encouraged to make choices, had the ability to greet visitors in private and had a varied and nutritious menu provided. EVIDENCE: The home employed two part time activity organisers. The monthly programme of activities was displayed. A number of residents said they were satisfied with the activities provided. The programme included flower arranging, ceramic classes, quizzes, shopping trips, exercises and watching T.V. Residents had access to the College clubhouse with its range of social events and to the College mini bus. A weekly church service was held in the home. Some residents chose to attend the service held in the chapel located in the college grounds. On the first floor staff should ensure that activity records, particularly for residents who are too frail to take part in group activities or outings, are kept up to date. The home had an open visiting policy and a number of residents said they enjoyed and benefited from regular contact with family and friends. On the first floor information about the level of input provided by relatives was recorded in residents care plans. Visitor rooms were provided for residents to entertain visitors in private and arrangements could be made for visitors to stay overnight or have a meal in the home. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 12 Feedback from residents was good. Residents said that they “could not fault the home”, “its perfect here” and “staff are kind and helpful”. Residents were encouraged to make choices about how and where they spent their time and staff were seen promoting choice at mealtimes and throughout the day. Meals were prepared in the College kitchens and brought to the home in heated food trolleys. The menus seen showed that residents had access to a varied and nutritious diet. Each floor had a kitchen area where meals were served, dishes washed and snack food and tea making available at all times. Residents were supported to choose their meal from the varied menu on a daily basis. From the records seen this was done. A cleaning schedule for the kitchen was up to date and fridge temperatures were recorded daily. A number of residents commented on the high quality of meals provided. Lunch was observed and staff served this efficiently and residents were allowed time to enjoy the meal. Staff offered assistance and prompting where needed. Feedback from residents was very positive about the quality of meals and meal choice provided. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Complaint procedures were satisfactory. Some amendments were needed to adult protection procedures to ensure staff fully understood how to manage and report allegations of abuse and the process of referral to POVA. EVIDENCE: The complaints procedure was displayed in the reception area and on each unit. The procedure included a timescale for responding to complaints and contact details for the Commission. Since registration no complaint had been made to the home or the Commission about the service. Staff had received training about abuse and were familiar with the procedure for reporting allegations of abuse or misconduct. Staff who spoke to the inspectors indicated they had a good understanding of adult protection and how to handle an allegation of abuse. The home was working with other agencies to ensure the safety of one resident who was known to be vulnerable. The adult protection procedure was printed in 2003. The adult protection procedure did not indicate that the lead agency into any abuse allegation is social services and indicated that CSCI should be notified if the allegation is proven. The Commission must be notified under regulation 37 about all allegations of misconduct or issues that affect resident’s health and safety. The procedure also indicated that the Commission would arrange for staff members to be included on the POVA list in the event of an allegation being upheld. It is the employer’s responsibility to refer staff found not suitable to work with vulnerable adults for inclusion on the POVA list. Requirements 3 and 4. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 to 26. The environment was clean, tidy and being a new building was in good condition. The environment was suited to meeting the category of resident in the home. EVIDENCE: The building and most of the furniture and fittings were new. The standard of decoration was good and quality furniture was provided for resident’s rooms and communal areas. No maintenance issues were identified. All bedrooms had en-suite units with w.c, washbasin and shower. On the ground floor residents said they did not have enough shower chairs to enable them to use their shower. The manager said that additional chairs had been ordered. The home also had adequate assisted baths and toilets. Grab rails were provided in corridors and by toilets. Ceiling and portable hoists were provided to ensure safe moving and handling of residents. Bedrooms were clean and tidy and residents said they were satisfied with their personal space. As this was a new home there were no maintenance issues Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 15 noted in relation to bedrooms. Staff on the ground floor were concerned that residents would not be able to bring in their own furniture items but the manager said that this could be arranged on request. A nurse call system was provided and readily available in bedrooms, bathrooms and communal areas. The home was clean, tidy and odour free. Clinical waste was stored appropriately. Staff had access to infection control training and antiseptic hand gel was provided in key areas. Staff were provided with protective clothing. The manager was testing out a new cleaning system, which involved using water and special cleaning cloths as opposed to a variety of cleaning agents. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staffing levels were good and staff had access to training relevant to their roles. Some improvements were needed to ensure all employee files contained the information required by regulation. EVIDENCE: The number and mix of staff on each shift was good. Staff communicated effectively and were approachable and helpful. Retention of staff was good and agency staff were used infrequently, which provided good continuity of care for residents. Staff rotas seen indicated above minimum staffing levels were maintained. At the time of this nursing care was being provided on the ground floor. This conflicted with the registration category for this floor and the matter will be brought to the attention of the Commission’s legal department for clarification. Once the legal position is clarified the matter will be discussed with the provider. Six employee files were inspected. These were well maintained and contained most of the information required by regulation. The manager said that some staff had been employed prior to the introduction of the National Minimum Standards and some of their information was held within the College. The manager was slowly ensuring files were up to date and complied with regulation. Prior to employing nurses the manager checked their registration with the Nursing and Midwifery Council and rechecked all nurse registration annually. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 17 Staff felt supported and were satisfied with the arrangements for training. The home employed a training coordinator who arranged vocational and mandatory training for staff and maintained staff training records. Two staff records were inspected and showed that both members of staff had attended a variety of relevant training sessions during the past year. Staff who spoke to the inspectors were satisfied with the management support they got and the training provided. Requirement 5. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. The home was well managed and systems were in place to ensure the safety of residents and others. A full quality system had yet to be implemented. EVIDENCE: The manager is registered with the Commission and has been assessed as fit to manage the service. Care managers on each unit who were involved in direct care delivery supported the manager in her role. The manager had purchased a quality assurance system and was in the process of adapting this to use in the home. The manager planned to do an annual satisfaction survey of residents. Currently monthly management and clinical meetings were held to address issues. The Commission received reports in line with regulation 26 monthly. Residents had a lockable space in their rooms to store valuable personal items and money. Resident’s personal money could be handed to care staff or the Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 19 accounts department for safekeeping. The system was rather complex but appeared safe. Regular checks and audits were undertaken. The financial records for two residents were checked and found to be satisfactory. Money was stored in the college account but a separate account had recently been opened for resident’s personal finances. The home had a policy and procedure on supervision. Individual supervision files were kept for staff. Five files were inspected and showed formal supervision was undertaken on a regular basis and address staff training and clinical practice. Some doors opened outwards onto corridors, which could pose a health and safety risk for staff and residents. It is recommended that this be risk assessed and remedial action taken if necessary. Staff had undertaken a formal risk assessment for residents requiring bedrails. There was no evidence in the assessment that staff had implemented strategies to reduce the risks associated with the use of this equipment. A selection of safety records were checked and found to be up to date. This included areas such as fire safety, hoist and assisted bath services, lift service and others. Fire drills were held at times to ensure night and day staff attended. As the home is a new building it had a 10-year builder’s warranty cover. Employers liability insurance was up to date. Requirement 6 and recommendations 2 and 3. Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X 3 X X 3 X 4 STAFFING Standard No Score 27 4 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? First inspection 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 OP7 Regulation 15 Requirement The Registered Person must ensure care plans are prepared in consultation with residents or their representatives to show how identified needs will be met. This requirement refers to the care planning on the ground floor. The Registered Person must ensure receipt and recording of medicines enables an audit trail to be completed. When staff write the medicine on to the medication administration chart they must transcribe the details as they are on the pharmacist label. Staff must take care when checking medicines brought into the home to ensure they identify any errors in relation to prescribed dosage. The Registered Person must ensure the procedures in relation to adult protection make it clear that all allegations of abuse are referred to the adult protection team at social services for investigation. It is the employer’s responsibility DS0000058195.V269904.R01.S.doc Timescale for action 27/03/06 2 OP9 13 20/03/06 3 OP18 13 27/03/06 Cullum Welch Court Version 5.0 Page 22 4 OP18 37 5 OP29 19 6 OP33 24 to have a system in place to refer staff found not suitable to work with vulnerable people for inclusion on the POVA list. The Registered Person must 27/03/06 ensure the homes procedures indicate that all allegations of abuse or misconduct are referred to the Commission under regulation 37. The Registered Person must 27/03/06 ensure the information required by regulation and schedule 2 is obtained for all employees and available for inspection. The Registered Person must 27/03/06 ensure the quality assurance system is implemented and a report on any review of the service sent to the Commission. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The Registered Person should ensure staff on the first floor understand the difference between assessments and care plans. If necessary training should be provided to address this issue. The Registered Person should undertake a risk assessment on doors that open out on to corridors. The outcome of the assessment and any remedial action should be sent to the Commission. The Registered Person should ensure staff implement strategies to reduce risks associated with the use of bedrails. 2 OP38 3 OP38 Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Cullum Welch Court DS0000058195.V269904.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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