CARE HOMES FOR OLDER PEOPLE
Deansgrove Residential Care Home 38 Bluebell Lane Huyton Knowsley Merseyside L36 7XZ Lead Inspector
Daniel Hamilton Unannounced Inspection 12th October 2005 9:30 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 Deansgrove Residential Care Home DS0000021481.V257779.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. Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Deansgrove Residential Care Home Address 38 Bluebell Lane Huyton Knowsley Merseyside L36 7XZ 0151-489-1356 0151 489 8289 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) Mr James Edward Jenkins Ms Susan Cornmell Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17), Physical disability over 65 years of age of places (17) Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 17 OP and up to 17 PD(E) Date of last inspection 4th May 2005 Brief Description of the Service: Deansgrove is a small residential care home which is registered to provide personal care and support for up to 17 older people, including older people with a physical disability. It is located in an established residential area of Huyton within approximately a mile of the town centre. The home is not purpose-built but has been adapted from existing properties. It is situated on two floors and has access to upper floors via a passenger lift and stair lift. On the ground floor there are two small lounges, a conservatory / dining room, a kitchen, office, laundry and some bedrooms. The first floor consists solely of bedrooms. The care home is equipped with adequate bathing and toileting facilities which are spread evenly throughout the premises. There is a large back garden to the home, which can be accessed via the conservatory. The side of the premises is currently being redeveloped to accommodate a further 12 bedrooms with ensuite facilities. This work is near completion. Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 9 hours. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The manager, owner, two staff on duty and 6 of the seventeen residents were spoken to during the visit. Leaflets were also left in the home to enable residents and others to comment on the service provided. What the service does well: What has improved since the last inspection?
Pre-admission assessments had been completed by the manager for all residents. Medication records had been correctly completed to record the administration of medicine and to confirm the receipt of medication into the care home. There were no controlled drugs in the home at the time of the visit. Menus had been updated to include a choice of meals and residents confirmed they had a choice of meals. An electrical safety, fire extinguisher, passenger lift and hoists service certificate had been obtained and copies had been forwarded to the Commission. Records showed that the fire alarm system had been tested on a weekly basis, except for periods when the new system was being installed. A copy of the local authority adult protection procedures had been obtained. Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 6 What they could do better:
The home’s assessments should be completed in more detail, to clarify the needs of potential residents. Likewise, care plans must be produced for all residents, which identify the needs of residents and the support required from staff. Furthermore, care plans must be kept under monthly review, to ensure the needs and support requirements of residents are closely monitored. Central records for health and personal care should be replaced with individual records and these should be stored in residents’ individual files. This will assist the home to monitor health care appointments more easily and to ensure confidentiality is maintained. The practice of continuing to support residents to self-administer their medication without having completed a risk assessment is not safe. Risk assessments must be completed for residents who self-administer medication. Although the majority of residents spoken with complimented the meals provided, a number of residents expressed concern about the early repetition of meals, due to having a two-week rolling menu. Service users should be consulted about the introduction of a 4-week menu, to provide more variation. The home had two complaints procedures in place. One procedure should be developed, to clarify the complaints procedure for residents and their representatives. Furthermore, the details of complainants and the outcomes of all complaints should be recorded. One member of the home had been dismissed since the last inspection and been referred to the Protection of Vulnerable Adults (POVA) list. The local authority adult protection procedures had not been followed correctly. In order to ensure a proper response to suspicion or evidence of abuse in the future, the procedures should be followed. Recruitment practice was poor and pre-employment checks, certificates and references were not in place for a large number of staff working in the home, despite a requirement at the last inspection. Staff must be recruited correctly, so that the people living in the home are protected. Some areas of the home were in need of repair / redecoration. An action plan must be developed, to ensure the outstanding areas requiring redecoration / repairs are rectified. Some staff had not received appropriate induction and all the necessary safe practice training. Furthermore, some training records were not up-to-date. These matters must be addressed to confirm staff are appropriately trained to undertake their role effectively. Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 7 The home should continue to develop its quality assurance processes in partnership with residents and /or their representatives, to ensure the home is run in the best interests of residents. The home did not have suitable arrangements in place for the management of residents’ monies, as the registered provider was retaining personal money belonging to residents in a business bank account. Money belonging to each resident should be paid into individual bank accounts. The absence of radiator guards had not been risk assessed and a service certificate was not available for inspection, despite a requirement at the last inspection. These issues must be addressed, to ensure the health and safety of residents is safeguarded. 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. Deansgrove Residential Care Home DS0000021481.V257779.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 Deansgrove Residential Care Home DS0000021481.V257779.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): 3 Assessments had been completed prior to admission, to enable the home to identify the care needs of prospective residents. EVIDENCE: Four files were viewed. Two were for residents who had recently moved into the home and the other two were for residents who had lived in the home for over six months. Individual assessment records were available for each resident. Records showed that the manager had undertaken a pre-admission assessment for each resident, however the information contained within the home’s assessments was very basic and provided limited information. One assessment was not dated. Assessments completed by social workers were also available on each file. Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 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 and 9 Care plans were not in place for all residents and some did not identify all the needs of residents. Furthermore, medication practice was still not satisfactory as safeguards were not in place for residents who self-administered their own medication. These shortfalls have the potential to place residents’ health and wellbeing at risk. EVIDENCE: Four files were viewed. Two files did not contain a plan of care to record the action required by staff to ensure that all aspects of the health, personal and social care needs of individual residents were identified and planned for. This situation was also found at the last inspection, when a requirement was issued to develop care plans for all residents. Although care plans were in place on the other two files, the plans did not detail all the needs of the residents and had not been kept under monthly review. Furthermore, none of the residents spoken with had any knowledge of the existence of their individual care plans. Supporting documentation including risk assessments for moving and handling, personal care and daily report records were also available. Health care records for each resident were recorded together in a daily report book. Records showed that residents had access to a range of health care
Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 11 professionals including; district nurses, physiotherapists, dentists, chiropodists, doctors and opticians. Some chiropody records did not detail which residents had received treatment. Residents spoken with confirmed that they received health care intervention subject to need. A resident reported; “I have seen the doctor recently and the district nurse visits me each day to dress my leg.” The home had a medication policy in place and a record of staff authorised to administer medication, sample signatures and photographs of residents were stored on file for verification purposes. Despite a requirement at the last inspection, a resident was still self-administering medication without a risk assessment. Medication administration records had been correctly completed to confirm the administration and receipt of medication into the care home. At the time of the visit, there were no controlled drugs in the home. . Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 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): 12,13,14 and 15 Some residents felt that the range and frequency of activities within the home remained poor and did not provide daily variation and interest. Visiting times were flexible and residents retained control of their daily lives in order to maintain their relationships and preferred lifestyles. Residents received a choice of meals, which were appealing and wholesome. EVIDENCE: Residents continued to express mixed views about the range and frequency of activities provided in the home. For example, one resident spoken with said; “I am quite happy with the range of activities provided” and another reported; “Not many residents are interested in activities”. Conversely, comments from three other residents included; “I still think the range of activities provided is poor”; “There are not many activities in the home” and; “A lady comes on a Wednesday and does some exercises for an hour. Other than that there are not many activities.” Since the last inspection, the home had purchased a portable pool table and a table tennis set. A selection of board games were also available for residents to access. An occupational therapist continued to visit the home each Wednesday for an hour and staff were assigned two hours each day to assist residents with activities. The home’s activities record was viewed. The record did not always detail which residents had participated in activities and showed that activities were not organised on a regular basis. There was no activities programme in place.
Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 13 The home had a ‘Policy on Visiting and Visitors’. Residents interviewed confirmed that visiting arrangements were flexible and that they were able to maintain links with family and friends both inside and outside the home. Comments from residents included; “There is no problem with visiting. Visitors are encouraged to visit at any time” and; “My son and daughter in law visit me each week. They can come whenever I want.” One resident reported that he was able to access the local community with support and had recently visited a local shopping centre with two friends. Residents spoken with confirmed that they were able to exercise their right to make choices and to maintain control of their own lives. The views of three residents included: “I pretty much have control of my life”; “No-one tells me what to do. I decide what I do and when” and “There are no restrictions on us. I haven’t been told what I can or cannot do.” Residents were able to bring personal possessions into the home and rooms viewed had been personalised with pictures, ornaments and personal belongings. Following the requirement at the last inspection, the menus had been updated to include a choice of meals for each sitting and a number of residents spoken with were able to confirm that they were offered choices. Comments included; “You do get a choice but I’m happy with the main menu” and “Mike the chef is very good. He offers me a choice.” The home had a two-week rolling menu in operation, which detailed a selection of wholesome and nutritious meals. Overall, residents complimented the meals provided however, some residents felt a two-week rolling menu led to early repetition of the meals available. For example, a resident reported; “The menu is very repetitive, but the food is good.” Meals were served in the home’s conservatory, which was pleasantly furnished and spacious. Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 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 and 18 Although the outcomes of two complaints had not been recorded, residents spoken with were confident that any concerns would be listened to and acted upon. Adult protection procedures were not being appropriately followed, to protect the people living in the home from suspicion or evidence of abuse. EVIDENCE: The home had two complaints procedures in place, which contained different information. One procedure should be developed, to clarify the complaints procedure for residents and their representatives. The complaints record showed that two complaints had been received since the last inspection. One record did not detail the name and contact details of the complainant and both records did not detail the outcomes of each complaint. Residents spoken with had no complaints about the home and were confident that the manager would address any concerns they might have in the future. Residents confirmed they had received a copy of the complaints procedure. Since the last visit, only one member of staff had completed training on the protection of vulnerable adults from abuse. Furthermore, the home had obtained a copy of the local authority’s Adult Protection procedures, although the procedures had not been followed correctly for a member of staff who had been dismissed from the home during July 2005. The staff member had subsequently been referred to the Department of Health, for inclusion on the Protection of Vulnerable Adults (POVA) list. Staff interviewed demonstrated an awareness of the concept of abuse and reporting procedures. Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 15 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 Some parts of the home remained in need of repair / redecoration, to ensure residents benefited from safe, comfortable surroundings. EVIDENCE: The building programme, to develop the side of the building in order to increase the bed capacity of the home by a further 23 beds, was near to completion. Some parts of the existing home had been affected by the building work and were in need of repair / redecoration. Despite a requirement at the last two inspections, two rooms had still not been redecorated. Deansgrove Residential Care Home DS0000021481.V257779.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): 29 and 30 Recruitment issues identified at the last inspection had not been fully addressed. Furthermore, recruitment practice was poor and did not safeguard or protect residents. Training records were not up-to-date, to confirm that staff were sufficiently trained and competent to do their jobs. EVIDENCE: The home had a ‘Policy on Recruitment’ in place. Despite a requirement being issued at the last inspection, 12 existing staff did not have a Criminal Record Bureau certificate on file. Furthermore, files viewed did not contain all the necessary information required under the Care Home Regulations. The manager reported that there had been problems with the Criminal Records Bureau Department processing payments and a systems failure, which had led to the need to re-issue new application forms to some staff. Documentary evidence of correspondence from the Criminal Records Bureau department was provided, to verify the home’s position. Two new staff had commenced employment at the home since the last inspection. Recruitment records confirmed that both the new staff had also commenced employment without a Protection of Vulnerable Adults check and files did not contain all the necessary information required under the Care Home Regulations. Despite a requirement at the last inspection, induction records were not in place for the new staff or for staff who had commenced employment around the time of the previous inspection. The manager reported that she had nominated 5 staff for induction and National Vocational Qualification (NVQ) training, however records were not available to confirm bookings.
Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 17 Training records viewed were not all up-to-date and showed that some staff had not completed all safe practice training. Staff spoken with confirmed they had access to a good range of training. Deansgrove Residential Care Home DS0000021481.V257779.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): 33, 35 and 38 Further work was needed to develop the home’s quality assurance system, in order to demonstrate that the home is run in the best interests of residents. Inappropriate arrangements were in place, to protect the financial interests of residents who required support with personal allowances. Some important records and safeguards were not in place, to protect the health, safety and welfare of residents. EVIDENCE: No residents meetings had been coordinated since March 2004. A basic ‘Residents Questionnaire’ had been produced, which the manager reported had been circulated during January 2005. No responses had been received. Likewise, feedback was not obtained via questionnaires from relatives or other stakeholders. The manager reported that she was an appointee for one resident and that the home looked after the personal money of 8 residents. Transactions were recorded in a record book and receipts were obtained. Cash received by residents / representatives was signed for on envelopes, not alongside the
Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 19 respective transaction record. The balance of residents’ personal monies could not be checked, as monies were retained by the Registered Provider in a central business account. Despite a requirement at the last inspection, a service certificate had not been forwarded to the Commission for the stairlift. Furthermore, the absence of radiator guards had not been risk assessed, to protect the welfare of residents. The Registered Provider reported that the new boiler would regulate the hot water tap outlet temperatures in residents’ rooms to 37°C. Fire records were inspected. Fire alarm tests had been conducted each week except for the period when the fire alarm system was being installed and commissioned. Visual checks on the emergency lighting were carried out on a monthly basis. Training records showed that some staff had not completed training in all safe practice areas. Deansgrove Residential Care Home DS0000021481.V257779.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 1 8 3 9 2 10 X 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 2 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 X X 2 Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 21 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 2 Standard OP7 OP7 Regulation 15 15 (1) Requirement The Registered Manager must ensure that care plans are reviewed on a monthly basis. The Registered Manager must ensure that each service user has a care plan that identifies their individual needs (as detailed in the assessment) and the action required by care staff to ensure that identified needs are met.(Previous timescale of 4/07/05 not met) The Registered Manager must ensure that service users who self medicate have risk assessments in place. (Previous timescale of 30/08/2004 not met). The Registered Manager must produce an action plan, with timescales, for the areas identified during the inspection as requiring redecoration / repair and a copy forwarded to the Commission. (Previous timescale of 4/07/2005 not met). The Registered Manager must ensure that all staff have a CRB check completed. (Previous
DS0000021481.V257779.R01.S.doc Timescale for action 12/11/05 12/12/05 3 OP9 13 (4) 12/11/05 4 OP19 23(2)(b) 12/11/05 5 OP29 19 (1) 12/11/05 Deansgrove Residential Care Home Version 5.0 Page 22 6 OP29 19 (4) 7 OP29 19 (4) 8 OP30 18 9 OP30 18 10 OP38 18 (1) a 11 OP38 13 (4) 12 OP38 23 (2)(c) timescale of 31/10/2004 not met). The Registered Manager must obtain a CRB and POVA check for all staff employed since the 26th July 2004. (Previous timescale of 4/08/05 not met). The Registered Manager must ensure that all staff files are brought up-to-date to include the documentation outlined in schedule 2 of the Care Homes Regulations. (Previous timescale of 4/08/05 not met). The Registered Manager must ensure that all staff receive induction training in accordance with TOPSS specification. (Previous timescale of 4/06/05 not met). The Registered Manager must ensure that all staff have an upto-date record of induction and training completed. The Registered Manager must ensure that safe practice training is completed by all staff and refresher training must be completed periodically. The Registered Manager must ensure that the absence of any radiator covers is risk assessed for each service user. Planned installation work must be prioritised according to the level of risk identified. (Previous timescale of 4/07/05 not met). The Registered Manager must ensure that a copy of the service certificate for the stair lift is obtained and a copy forwarded to the Commission for Social Care Inspection. 12/11/05 12/11/05 12/11/05 12/11/05 12/12/05 12/11/05 12/11/05 Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 23 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 2 3 4 5 Refer to Standard OP3 OP8 OP12 OP15 OP16 Good Practice Recommendations The home’s pre-admission assessments should provide more detail on the needs of residents. Individual health and personal care records should be established and stored in each resident’s file. A programme of activities should be developed in consultation with residents and the range and frequency of activities provided should be improved. Service users should be consulted about the introduction of a 4-week rolling menu, to avoid early repetition of the menu. One complaints procedure should be developed, which meets the requirements of Regulation 22. Furthermore, the outcome / action taken in response of all complaints should be clearly recorded on the respective complaints form. The registered manager should follow the local authority adult protection procedures whenever there is suspicion or evidence of abuse. Quality assurance systems and practice should be further developed, to ensure the home is run in the best interests of residents. Money received by residents or their representatives should be signed for alongside the respective transaction record. The Registered Provider should not retain money belonging to residents in a business bank account. Money belonging to each resident should be paid into individual bank accounts. 6 7 8 9 OP18 OP33 OP35 OP35 Deansgrove Residential Care Home DS0000021481.V257779.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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