Inspection on 10/12/07 for Dudley House Care Home

This inspection was carried out on 10th December 2007.

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

Dudley House Care Home 03/07/07

Dudley House Care Home 23/10/06

Dudley House Care Home 04/04/06

Dudley House Care Home 23/01/06

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Dudley House Care Home The Grove Isleworth Middlesex TW7 4JF Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 10th December 2007 10:20 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 Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dudley House Care Home Address The Grove Isleworth Middlesex TW7 4JF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8560 9560 020 8568 7082 dudleyhouse@eurotelonline.com Dudley House Care Home Ms Lynette Maggs Care Home 40 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (40), Physical disability (40), Physical disability over 65 years of age (40), Terminally ill over 65 years of age (1) Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. As agreed on 02/05/2006, one named service user over the age of 65 with Terminal Illness can be accommodated within the home. Service users who already have a diagnosis of Dementia may not be admitted. Service users who develop Dementia after being admitted, may be accommodated, as long as their needs can be met and they do not detrimentally affect the wellbeing of the other service users. 3rd July 2007 Date of last inspection Brief Description of the Service: Dudley House Nursing Home is a large detached house in Isleworth. There are 38 single bedrooms, 11 of which are en suite, plus one double bedroom. The home has installed a new larger passenger lift. There are three floors in the home and resident accommodation is provided on all three floors. There are also bathroom facilities on all three floors. The home has a lounge/dining area and another small sitting room with access to the rear garden. New offices have been built onto the rear of the building. The home is located nearby to Isleworth train station and is also a short walk from the London Road, which is served by several bus routes. There are shops in Isleworth itself and the home is a short bus ride from Hounslow Town Centre. There were 38 residents accommodated at the home at the time of inspection. The fees range from £540 to £680 per week. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 14 hours was spent on the inspection process, and was carried out by 2 Inspectors. The Inspectors carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 10 residents, 9 staff and 1 visitor were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, representatives/visitors, staff and health & social care professionals have also been used to inform this report. Where any issues were raised on the comment cards these have been fed back to the home in general terms. What the service does well: What has improved since the last inspection? Overall the service user plans are well completed and healthcare needs are also being identified and met. Completion of wound care documentation has Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 6 improved. Medications are now being well managed at the home. Staff were heard speaking with residents using their preferred term of address. The home now has a full time activities co-ordinator in post and information regarding individual hobbies and interests was available. Systems are in place for effectively reviewing the quality of care provided and for reviewing all aspects of the home for quality assurance purposes, and regulation 26 inspections are being undertaken. There had been an improvement in staff training to include wound care and health & safety topics. 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. The summary of this inspection report can be made available in other formats on request. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home is now using the ‘Standex’ care planning system, which has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Pre-admission assessments had been completed for the residents records viewed. The home also obtains a copy of the needs led assessment undertaken by social services. The surveys received from residents indicated that they receive contracts and terms & conditions. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were being completed to provide staff with the information to meet each resident’s needs. Shortfalls should be easy to address. Medications are being well managed at the home, thus safeguarding residents. Staff care for residents in a caring, gentle and professional manner, thus respecting their privacy and dignity. Information regarding the wishes of residents and their families in respect of end of life care is ascertained, thus their wishes can be respected. EVIDENCE: One Inspector viewed 3 service user plans and overall these were well completed and provided a good picture of each resident and their needs. There was evidence that documentation had been reviewed monthly and also whenever there was a significant change in a residents’ condition. The documentation includes a long-term needs assessment that records each area of need and some information regarding how this is to be addressed. Care plans are then formulated for any problem areas identified. The Inspectors recommended that the Acting Manager check through each service user plan to Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 10 ensure that care plans had been formulated for each problem identified. Risk assessments for falls had been completed, however one viewed had not been updated following a fall, and this was done at the time of inspection. The fall had been recorded in the daily record. Risk assessments for the use of bedrails had not been transferred to the new documentation and in some cases were not in place. Written consents for bedrail use were seen. The importance of ensuring all risk assessment documentation is complete and up to date was discussed with the Acting Manager. There was evidence of input from the residents and their representatives in the service user plans viewed. Wound care documentation was comprehensive and up to date. Assessments for pressure sore risk were in place. Pressure relieving equipment was in place and recorded in the service user plan. Moving & handling assessments were in place and the moving and handling equipment in use had been identified in the plan, however not always with the moving & handling assessment and the Inspectors recommended this be put in place so that the information was easy to access. Nutritional assessments had been carried out. The home uses the Primary Care Trust continence assessments and the Acting Manager said that he would find out if the ‘Standex’ system provides a continence assessment for inclusion with the other documentation. There was evidence of input from healthcare professionals to include GP, tissue viability nurse, community matron, chiropodist, optician and the activities co-ordinator who is a qualified physiotherapist. One inspector viewed the medication management. Since the last inspection the home has transferred to using a monitored dosage system (MDS). A list of staff signatures was available. Liquid medications had been dated when opened. Receipts, administration and disposal of medications had been recorded. The fridge temperatures were being recorded, however the records did not appear fully accurate. Following the inspection a new form has been devised to ensure the minimum, maximum and actual fridge temperatures plus the room temperature are being accurately recorded, plus the thermometer must be reset following each reading. A copy of this form with correct temperature records has been forwarded to CSCI. Controlled drugs were being appropriately stored and recorded. Stocks were checked for 3 medications and found to be accurate. The need to ensure all entries are made in black ink was discussed. Lancing devices for professional use are now being used for carrying out blood glucose monitoring. For residents being fed via a percutaneous endoscopic gastrostomy tube (PEG) the timings are now being recorded on each individuals fluid balance chart. For good practice, each feed should be signed for on the medication administration record and the batch number recorded also. On the admission page of the service user plan the section regarding the residents’ end of life wishes had been completed in most instances and where an individual did not yet wish to discuss this topic this had been recorded. The home has input from the Macmillan nursing service and staff had received Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 11 some training with further training planned in end of life care. Care plans for end of life care are formulated at the appropriate time for the residents care needs. Staff were seen caring for residents in a gentle and professional manner and there was good interaction between residents and staff, with a happy atmosphere throughout the home. Staff were heard speaking to residents using their preferred term of address. Individual clothing is labelled and residents were well dressed, to reflect individuality. Bedrooms were personalised and overall looked very homely. Residents can have land line or mobile telephones and are encouraged to keep in contact with friends and family. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home has improved, providing a variety of activities, outings and entertainments to meet the residents needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, with resident’s choices being respected. EVIDENCE: The home now has a full time activities co-ordinator in place, and it was clear from discussions with her that she enjoys her work and understands the importance of providing activities that meet the interests and abilities of the residents. Two residents had been encouraged to play scrabble and now enjoy playing each day, which keeps their brains active. There is a comprehensive activities programme in place and this is structured into time slots throughout the day, reflecting the times that are most suited to the residents for various types of activities. For those residents who choose to spend time in their bedrooms, 1:1 time is scheduled in. The activities co-ordinator is a qualified Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 13 physiotherapist and gentle exercise sessions take place each day, and more intensive sessions take place for those for whom it is appropriate. The garden is utilised in good weather and residents enjoy going out. The activities coordinator said that outings are limited due to the lack of transport facilities provided in the area, plus the cost of taxi fares. She is pursuing this area. Monthly visits are made by representatives from the Church of England and Roman Catholic churches, plus a representative from the Brentford Free Church visits the home. Representatives from other religions can also be accessed as needed. Each resident has a life and social history page in the service user plan and a diary of activities is also recorded for each person. Special events were recorded on the activities programme for the Christmas festivities. At the time of inspection pupils from a local school attended to sing Carols for the residents, and everyone enjoyed the afternoon. The home has an open visiting policy and visiting is encouraged. The visitor spoken with said that they are made welcome at the home. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. Information for ‘Advocacy First’ advocacy services was on display in the home. The majority of the residents have a next of kin and social services are involved where no next of kin is available. One Inspector viewed the kitchen. This was clean and tidy and all the records were up to date. Residents spoken with said that they enjoy their meals and that choices are available, as evidenced on the menu. Pureed meals are well presented. Snacks and drinks are available throughout the 24 hour period. The home has a new chef commencing in January 2008 and in the interim period the ancillary staff who have completed food safety training are carrying out the cooking, in line with the menus available. Staff were available to assist residents with their meals and were seen doing so in a gentle and discreet manner. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. Policies and procedures are in place and are followed for safeguarding adults, thus protecting residents. EVIDENCE: Details of the complaints procedure are available and are also displayed in the home. There had been 5 complaints since the last inspection and all concerns, however minor, are recorded and fully investigated. The Acting Manager has an ‘open door’ policy for visitors, and does deal promptly with any concerns raised. Information on the surveys completed by residents and representatives evidenced that they are aware of the complaints process and that any issues raised are effectively addressed. The home has adult protection policies and procedures in place that dovetail with the Hounslow Safeguarding Adults documentation. Staff spoken with said that they had received POVA training and were clear to report any concerns. One POVA case had been investigated since the last inspection. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained, providing residents with a pleasant, homely and well-maintained environment to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: The home has a programme of redecoration and refurbishment and work is ongoing to maintain the home to a good standard. Since the last inspection the flooring in the ground floor corridor and communal room has been changed and this has made a positive improvement to the environment. Electric profiling beds have been purchased with more on order. Overall the home is being well maintained throughout. An inspection by the London Fire Emergency Planning Authority (LFEPA) had taken place in August 2007 and the requirements from this visit were being addressed. The Registered Person said that LFEPA will be carrying out a follow up visit to the home. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 16 One Inspector viewed the laundry room, which is in the basement. This was clean and tidy and the flooring was in the process of being replaced. Action has been taken to prevent flooding in the event of heavy rainfall. The home has the ‘Otex’ ozone disinfection system in place and this is in line with infection control. Protective clothing to include gloves and aprons is available and staff were seen using this appropriately. Training in infection control has been planned. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents can be met at all times. Systems for vetting and recruitment practices are in place to safeguard residents. There is a training programme in place to provide staff with the skills and knowledge to care effectively for the residents. EVIDENCE: At the time of inspection the home was appropriately staffed to meet the needs of the residents. Ancillary staff are employed in such numbers to meet the needs of the home. Any vacancies are recruited to and action is taken in the interim to provide effective temporary cover for these posts. It was clear that the Acting Manager and Responsible Person ensure that the staffing levels are maintained to meet the residents needs in all areas. 60 of the care staff have been trained to NVQ in care level 2 or higher, with further training planned. The home has a low turnover of staff and staff have the skills and experience to meet the needs of the residents in their care. Staff employment records were sampled. Those viewed contained the information required under the Care Home Regulations 2001. The home has an induction programme to meet the Skills for Care common induction standards and all new care staff complete the booklet. There is a Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 18 training programme in place and staff spoken with confirmed that they do receive training on a regular basis in topics relevant to their roles. The Acting Manager was aware of some gaps in training for which training days are being planned, and explained that he had identified other areas of training that had been prioritised due to shortfalls identified at the last inspection. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Acting Manager has the skills and experience to manage the home effectively and is planning to undertake training to provide him with the necessary qualifications for the role. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are being managed and securely stored. Systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Acting Manager is a first level nurse with general nursing and mental health qualifications. He has been a deputy Manager in another care home setting and has experience of working with older people. He has enrolled to undertake NVQ level 4 in management and is also in the process of completing Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 20 his Masters Degree in Business Administration. Staff spoken with said that they enjoy working at the home and that the Acting Manager and Registered Person are supportive and approachable, and any issues are discussed and addressed. The home has a system in place for quality assurance. Regular audits are carried out to include service user plans, wound management, medications, health & safety and fire safety. Regular residents and relatives meetings take place and minutes are recorded. Staff meetings take place regularly and again minutes are recorded. The Registered Person carries out Regulation 26 monthly unannounced inspections and copies of the reports from these visits are available. The annual satisfaction surveys for residents and relatives have recently been completed and the results are to be collated and published. Copies of the results for 2006 were available in the entrance hall. The Registered Person said that they are in the process of developing a website and video brochure for the home. One Inspector sampled records for residents’ personal monies held on their behalf by the home. A discrepancy was noted with one set of records and monies and action was taken to identify the reasons for this and take corrective action at the time of inspection. A clear explanation was found and records amended accordingly. Apart from this finding financial records were being well maintained with receipts and records for income and expenditure available and up to date. Monies are securely stored. Overall the records were being well maintained and were up to date. One incident had occurred where a resident had been found to have a small injury. This had been clearly recorded in the daily record and an accident form had been completed. The need to investigate such an incident to try and establish the cause of the injury and to record the outcome of this was discussed. Maintenance and servicing records were sampled and those viewed were up to date. Risk assessments for equipment and safe working practices were available. The fire risk assessment and the generic risk assessment for the home had last been updated in October 2007. Staff had received training in health & safety topics and further training was planned. Regular health & safety audits take place and records are maintained. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 21 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 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 13(4), 17 Requirement Risk assessments for falls and the use of bedrails must be in place and up to date, to clearly identify any risks and how these are to be minimised, to safeguard the residents. All records in respect of any incidents must be up to date and clearly reflect the action taken to address the situation, to minimise the risk of reoccurrence. Timescale for action 01/01/08 2. OP37 17 01/01/08 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. Refer to Standard OP7 Good Practice Recommendations An audit should be carried out of each service user plan to ensure that a care plan has been formulated for all problems identified. Information regarding the specific moving & handling equipment in use for each individual should be recorded on the moving & handling assessment so that the information DS0000064752.V353812.R01.S.doc Version 5.2 Page 23 OP8 Dudley House Care Home 3. OP9 is easily accessed. PEG feeds should be signed for on the MAR and the batch number recorded. Dudley House Care Home DS0000064752.V353812.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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