Inspection on 16/06/05 for Devonshire Court

This inspection was carried out on 16th June 2005.

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.

Other inspections for this house

Devonshire Court 28/07/08

Devonshire Court 04/05/07

Devonshire Court 17/10/05

Devonshire Court 04/11/04

Devonshire Court 24/05/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Devonshire Court Howdon Road Oadby Leicestershire LE2 5WQ Lead Inspector Gillian Adkin Unannounced 16 June 2005 09:30 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 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. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Devonshire Court Address Howdon Road, Oadby, Leicestershire, LE2 5WQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0116 2714171 0116 2717201 Royal Masonic Benevolent Institution Mrs Anthea Richards Care home with nursing 59 Category(ies) of OP Old age (59) registration, with number PD(E) Physical dis - over 65 (59) of places DE(E) Dementia - over 65 (10) MD(E) Mental Disorder -over 65 (10) Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No person may be admitted to the home who falls within categories MD(E) or DE(E) when 10 persons in total of these categories/combined categories are already accommodated within the home. Date of last inspection Brief Description of the Service: Devonshire Court is a large traditional care home built on a four and a half acre site. Built in 1966 and situated on the outskirts of the City of Leicester and in the residential area of Oadby, the home is close to the famous Leicester racecourse. It is within easy reach of the City by public transport or car. Wigston is also close by. The home was opened by the Queen Mother in 1966 and is owned by the Royal Masonic Benevolent Institution (RMBI). The home is a registered charity and offers accommodation to for up to fifty-nine service users who are elder Freemasons with nursing, residential or mental health needs. A separate unit accommodates the elderly mentally frail service users. The registered provider also offers respite facilities. The home has the following categories of registration Dementia - Mental Disorder, excluding learning disability or Old age Physical disability over 65 years of age The home has fifty nine single en suite bedrooms.Internal communal facilities include one large lounge and several quiet lounges on each floor. There are also two conservatories giving access to the patio area.A communal dining area is on the ground floor.Set in four and a half acres of land the home has mature gardens, which include a bowling green and patio areas. The registered provider has a minibus for external trips. Service users may use the extensive facilities, which include a functions room, billiards room, hairdressing room and chapel. The registered provider has installed voice messaging lifts, specialist signs and equipment to ensure that service users needs are fully addressed. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over one day and commenced at 9.15 am on 16/05/05.The inspection took 7.5 hours. The deputy manager facilitated the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting four residents and tracking the care they received through review of their records, discussion with them, and their relatives, care staff and observation of care practices. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. During this inspection a tour of the home took place and the inspector viewed internal records, and care plans. She also spoke to nurses including a Community nurse, care and ancillary staff, residents and relatives. Discussions with the registered manager regarding requirements made at the last inspection indicated that all of the requirements had been met. A recommendation regarding attention required to broken window seals is featured in this report. Comments were received from three out of four residents selected for case tracking. Additional comments made by residents about the service were very positive. comment received from a community nurse regarding the care /nursing provision were very positive. The nurse stated that “Care was Excellent” Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 6 What the service does well: What has improved since the last inspection? The level and quality of monitoring of residents nursed in bed has improved significantly. Records inspected were greatly improved. Care plans and their evaluation had improved and were reflective of all assessed needs and outcomes. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 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 standard(s) 3.4.5 A robust assessment process, which includes residents and there representatives, is in place. this results in them having confidence that the home can meet their needs satisfactorily. EVIDENCE: Four residents were case tracked and evidenced that where self-funding individuals received a robust internal assessment, which had been undertaken by the manager or deputy. Where residents are funded by external authorities evidence was in place to support an external assessment. Other assessments were noted which had been produced by other professionals involved in residents care. Three of the four residents tracked were able to confirm their involvement in initial assessments. Comments received from relatives, residents and external staff indicated that they were confidant that the home could meet their needs. All risks were identified in care plans and appropriately addressed. The home is a registered charity and accommodates residents who are elder Masons or Masons spouses. The admission process includes a trial visit option, which is fully documented in the RMBI documentation. Visitors in the home were unable to confirm their involvement in the admission process however Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 10 the deputy manager indicated that residents and their relatives are welcome to visit the home before admission. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7.8.9.10.11. Robust care planning and medication management results in residents’ health care needs being fully met Appropriate systems including policies and procedures and training of staff ensures that residents are confident that they will be treated with respect and dignity up to the time of their death. EVIDENCE: All four residents tracked had appropriate care plans in place, which fully detailed needs identified in the initial assessment. Care plans were reflective of all needs including medical, social and psychological. Observation of records and discussion with staff and residents indicated that in the main they are fully involved unless their medical condition prevents this such as those with mental health issues. Staff discussed with the inspector how they involve families in the evaluation process and where possible obtain signatures to confirm involvement/consultation. None of the residents tracked were able to confirm that they had been involved in their care plan or subsequent updating. In three out of four cases this was not possible due to medical condition and the fourth service user was new to the home and his relative had been involved prior to admission. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 12 Adequate evidence was found to support that resident’s healthcare needs were addressed and included the input of other professionals. All residents tracked have a named nurse who has responsibility for the evaluation of their care plans. All residents spoken with(excluding those case tracked who were unable to answer specific questions) stated that they were able to see the General Practitioner when required. A community nurse working in the home commented about the high standards of nursing care provided and evidence was found to indicate that a relative of a service user tracked had formally agreed with the General Practitioner that due to the high quality of care provided in the home they did not wish their relative to be admitted to hospital in the event of a deterioration in her health. Medication systems and management were inspected and all areas inspected were well managed, records examined were accurate and up to date. One of the residents tracked was responsible for the self-administration of inhaled medication. Risks associated with this practise had been formally addressed by staff in an assessment following agreement that he could manage this independently. Controlled drug stock was inspected and records /stock counted. All drugs were accurately maintained. Discussion with the deputy manager and observation of care records confirmed that negotiation had taken place with a resident (tracked) regarding management of pain and medication records supported choice and where agreed refusal of medication. Staff were questioned about the policy and procedure regarding management of errors and refusal of medication and all those involved were aware of the management process. Medication profiles were noted in care plans and supporting evidence was found which identified where additional drug information could be located for each prescribed medication. This is commended as good practise. NVQ training and Induction undertaken ensures that the needs of residents who are dying are met appropriately and with dignity. Two trained staff have attended community palliative care training and have planned to cascade this training to care staff. Trained staff are competent to manage medication and pain relief issues. Staff are well supported by outreach services such as Macmillan, Loros etc. Staff spoken with were aware of the organisations policies and procedures regarding the dying person. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14.15 Provision of good quality meals where choices and individual needs are considered results in resident’s nutritional requirements being met and overall satisfaction with food provided. EVIDENCE: Discussions with residents (where practicable) demonstrated that they are encouraged to maintain choice and control over their lives. Examples given included meal times, going to bed and getting up times. Two out of four residents tracked were unable to confirm how they were given choices, however one resident indicated that she did not consider that there was adequate choice for breakfast and only usually had toast. She further stated that she was not allowed a boiled egg. The resident complained that she did not get a choice of main meal, however during this discussion staff were observed to come into the room and discuss the choices of meal for the day. It was agreed with the deputy manager that further discussion should take place with the resident to ensure that they were made aware of risks associated with the serving of soft eggs and appropriate risk assessments put in place if the person still chose to eat them. It was further agreed with management that menus would be given to the resident in advance to ensure she was made aware of the menu choices and where necessary alternatives provided. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 14 Menus were not inspected on this occasion however residents spoken with commented on the quality of food served. Staff appropriately managed nutritional risks identified on care assessments and evidence was found to support involvement of professionals in this process. Discussions with care staff indicated that they were fully aware of nutritional issues and how they were managed. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16.18 Complaints are managed efficiently and responded to within given time scales. An adult protection procedure and appropriate training are in place to ensure staff are confident in responding to suspicion or allegation of abuse this ensures the protection of residents in the home. EVIDENCE: Two of the four residents case tracked were able to access and use the complaints procedure.Most other residents’ spoken with had a clear understanding of the procedure however a new resident was unsure who he would report concerns to. The individual was able to self-advocate and had the support of family. He stated that he thought he would discuss any problems with the staff member concerned. Discussions with the deputy manager identified that internal documentation had not been fully explained to the resident as he had only been admitted for respite care for one week initially and then admitted to hospital. He was still unwell following discharge and staff had been unable to fully explain this to him. Residents accommodated on the Dementia unit were unable to answer questions relating to complaints reporting. Discussions with residents and relatives and observation of staff at work demonstrated that residents are treated respectfully. Robust adult protection policies and procedures are in place, which are included in the initial induction and foundation programme for staff. A new policy regarding restraint has recently been developed and the draft copy was inspected. Staff when questioned regarding reporting alleged abusive incidents were aware of the whistle blowing policy and “ the Multi agency policy “ No Secrets”. The updated local policy was seen and evidence was Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 16 found to support that staff had read this new document. A registered nurse and the deputy manager provide adult abuse training for staff. The deputy manager was aware of the vulnerable adult reporting procedure. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20.22.24.26 Clean, safe and well maintained living areas and rooms, and provision of appropriate equipment and facilities ensure that residents live in surroundings, which maximise independence and are comfortable and homely. EVIDENCE: During this inspection all areas of the home including the rooms of those case tracked were clean, odour free, well decorated and were well maintained. Inspection of staffing rosters demonstrated that adequate ancillary staff are employed to ensure the cleanliness of the home. An ongoing maintenance and upgrading programme is in place. The home employs several maintenance personnel who are responsible for day-to-day repairs and general maintenance and associated records. A programme of replacing windows is ongoing and is in the second phase. Plans to increase the number of bedrooms in the home have been agreed with the CSCI and building work is due to commence in July 2005.Consultation with residents has taken place through residents meetings. There are ample internal and external communal areas, which provide residents with a choice of comfortable rooms including the conservatory to sit Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 18 in. Activities are conducted in the lounges and externally the grounds are safe, well maintained and accessible. Several residents freely accesses grounds in their electric wheelchairs/buggies. All rooms are single and en-suite providing rooms, which suit individual needs. Generic and individual risk assessments are in place to identify hazards, which may affect residents. It was identified through an individual case tracked that suitable consultation had taken place with the family and General Practitioner of a residents who was at risk of falling out of bed. This was fully documented in the care plan and had been signed by family. The resident was being nursed on mattresses on the floor of their room for safety reasons. Discussions with residents and observation of private accommodation demonstrated that they were able to personalise rooms to individual taste and bring in personal items of furniture by prior arrangement with the home manager. All rooms inspected included the provision of suitable equipment to meet the needs of the individual resident. Including nursing beds, Pressure relieving equipment and hoists etc. One lady spoken with who is blind stated that she knew where all her furniture was in the room and that staff knew not to move it. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27.28.29.30 The needs of residents are safely met by thorough a robust recruitment and selection process and adequate numbers of suitably skilled and trained staff. EVIDENCE: Inspection and calculation of staff rosters demonstrate that staffing levels and hours provided meet with the recommended guidelines of the previous registration authority. All of the four residents tracked were assessed with high dependency needs. All information identified in care plans and received from residents during the inspection indicated that staffing levels were adequate to meet their needs. Staff spoken with and observed appeared to be very busy and responding in a timely way to resident’s requests for assistance. No concerns were raised with the inspector regarding numbers or quality of staff. Discussions with staff demonstrated that they were aware of their individual roles and responsibilities. The organisation demonstrated that they are keen to develop staff and use a financial incentive scheme to ensure that staff move through induction /training swiftly. Training records identify that ongoing training is provided both internally and externally to ensure that staff are well trained. The skill mix of staff identified on duty rosters appears to be appropriate to meet the needs of residents in occupancy at this inspection. Staff files were inspected on this occasion and most essential documentation was in place photographic evidence was not found however to identify staff members. The registered manager stated that the administrator had commenced this process Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 20 however it was not completed. This process ensures that the quality of staff employed is conducive with the categories and needs of resident accommodated and that residents are safe from harm where unsuitable staff may be employed. Examples of interviews recently undertaken were seen and included specific questioning in relation to adult protection. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32.33.35.36.37.38 The effective leadership of the home and well-supervised staff who are aware of policies and procedures ensures that resident’s safety, best interests and rights are protected. EVIDENCE: Mrs Thea Richards is the registered manager and has responsibility for the day-to-day management of the home. She is a registered nurse who has been in post for a number of years. The deputy manager who is also a registered nurse manages the day to day clinical /nursing issues. Discussions with staff, residents and relatives demonstrated that both managers are pro -active in their roles and are very supportive towards them. Many care staff stated that Mrs Richards was very approachable. Observation of the deputy manager during the working day demonstrated that she ensures that residents’ needs are met and that she has a professional and sincere approach towards them. Corporate policies and Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 22 procedures are in place with regard to resident’s personal money these were inspected. Policies in place protect residents and ensure that financial interests are safeguarded. Staff induction includes the management of resident’s money and the receiving of gifts and gratuities. Staff spoken with were aware of these policies when spoken with. A large number of residents are able to manage their own personal affairs however where this was not possible relatives / and /or representatives were identified by them as being responsible for this. Residents tracked were unable to confirm if they had been made aware of the policies and procedures regarding personal money due to their medical condition however one resident informed the inspector that the home looked after his money and he was satisfied with the way it was managed. Records inspected demonstrated that supervision is undertaken approximately Bi- monthly. Records identified that a full range of topics are discussed and include performance and training needs. Annual appraisals are due in July 2005. Supervisors have been provided with training to ensure they are confident in their role. Health and safety records inspected include fire, accident and water temperature records. All records inspected were up to date and accurate and staff training included COSHH, Food Hygiene, Moving and Handling. Fire drills and lectures were up to date and held regularly as recommended. Two issues were raised with the deputy manager regarding health and safety in that a service user tracked had been found to have been trapped between bedrails recently. Staff spoke with were aware of the incident and had been informed of new management measures to ensure that monitoring was more vigilant. Records relating to the event were accurate and the risk assessment had been evaluated after the incident. Observation of the resident in her room indicated that current monitoring had been increased, but not fully documented. It was recommended that all monitoring visits be recorded in daily records. An inspection of the upper floor identified that a sluice room had not been locked and that disinfectant and washing up liquid were open and readily accessible. Two kitchenettes, which were also unlocked contained washing up liquid and both issues were identified as serious health and safety matters which could place residents at risk of harm or serious injury. An immediate requirement notice was issued to the registered manager with a requirement to take action to address these matters. Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION x 3 x 3 x 3 x x STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x 3 3 3 1 Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 24 NO Are there any outstanding requirements from the last 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 38 Regulation 13 Requirement The registered provider must put appropriate measures in place to ensure that residents are protected from harm by ensuring that chemicals stored in sluices and kitchenettes are securely locked away. Staff files must have photographic identity put in place by agreed timescales. Timescale for action Immediate 2. 29 19 Schedule 2 16.07.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 Page 25 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park, Enderby Leicester LE19 1SX 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 Devonshire Court C51 S1898 Devonshire Court V233282 160605.doc Version 1.30 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. 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