Inspection on 14/11/06 for Eastridge Manor

This inspection was carried out on 14th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Similar services:

Deepdene Care Centre

Ferndale Residential Care Home

David Gresham House

Elizabeth House

Elvy Court Nursing Home

Fontenay Nursing Home

Clairmont Residential Home

Cornford House

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

CARE HOMES FOR OLDER PEOPLE Eastridge Manor Wineham Lane Bolney Haywards Heath West Sussex RH17 5SD Lead Inspector Mrs D Peel Unannounced Inspection 14th November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eastridge Manor DS0000065674.V307515.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. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastridge Manor Address Wineham Lane Bolney Haywards Heath West Sussex RH17 5SD 01444 881768 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) South Coast Nursing Homes Limited Ms Anne Mabey Care Home 32 Category(ies) of Dementia (32), Old age, not falling within any registration, with number other category (4) of places Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 4 persons in the OP category may be accommodated, with the total number of people not exceeding 32. First visit since registration with current providers. Date of last inspection Brief Description of the Service: Eastridge Manor is a Care Home, which provides care and support to elderly people who have dementia and other related mental disorders. It is currently registered to accommodate up to thirty-two residents. The home is a detached property, which has been extended and refurbished to a high standard and it is set in its own extensive grounds in the rural village of Wineham in West Sussex. Communal accommodation consists of two lounges, a dining room, a conservatory and a large hall where residents like to sit in the comfortable armchairs and a sofa. Private accommodation consists of twenty-nine single rooms of which twentyseven have en suite facilities and two double rooms, which can be used as either double or single rooms. Both double rooms have en suite facilities. The registered provider is South Coast Nursing Home Limited and the person responsible for the day-to-day running of the establishment is Ms Anne Mabey, the registered manager. The current scale of fees being charged at the home is from £500 to £600 per week. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by Mrs Diane Peel, and Mrs Jeanette Dattoo, a pharmacy inspector on the 14th November 2006. This was the first visit to Eastridge Manor since a change of registered provider in May 2006. As a new registration the home was required to be inspected within the first six months. The intended outcomes for 33 standards were assessed; these included the key standards for care homes providing a service to older people. Prior to the visit to the home an inspector reviewed information gathered during the process of registering the home with the Commission for Social Care Inspection (CSCI) in May 2006 and a pre inspection questionnaire completed by the manager of the home at the request of the lead inspector some weeks prior to the visit. An inspector reviewed information provided by a relative who’s parent had recently died at the home after living there for a number of years. They wanted to share their positive experiences of the home. A case tracking exercise for four residents was undertaken to look at how the assessed needs of this group of residents with diverse needs were being met. The inspectors spoke with residents living at the home whilst visiting them in their bedrooms, or in the lounges and at lunchtime in the dining room. A relative visiting a resident was spoken with during the visit to find out their views on the quality of care received by their relative living at the home and an inspector met with a visiting District Nurse to discuss access to health care and their opinion of the facilities provided by the home and the care being provided. The pharmacist inspector viewed medication storage and records of medication receipt and administration, spoke to staff about medication procedures and observed administration practice. The records of four staff were inspected and staff were spoken with informally during the visit to find out what it is like to work at the home. Samples of other records required to be kept by the home were viewed during the visit to ensure that the provider is meeting their obligations with regard to the administration of the home. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? This is the first visit to the home since it was registered with the current providers in May 2006. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 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. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 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 Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 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): 1,2,3,4,5,6 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. A variety of information is available to help prospective residents and their relatives to make an informed choice about the suitability of Eastridge Manor as a place to live. All residents and their representatives have contracts so that they know what is included in the fee and what the terms and conditions of living at the home are. All new residents have a full needs assessment before they move into the home to make sure that the home can meet their needs. Prospective residents are encouraged to spend time at the home to test out what the home can offer and to see if they feel that they would be able to settle in. EVIDENCE: Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 10 Eastridge Manor has a Statement of Purpose and Service User Guide, which is regularly updated. A copy was provided prior to the visit to the home. The document was observed to provide comprehensive information about the service. The organisation has a website which prospective residents relatives can access to find out about the service, its location and what the home is able to offer. The care records of two residents who had recently moved into the home were viewed at this visit and they were observed to include a comprehensive needs assessment, which had been carried out prior to them, moving into the home. The Statement of Purpose and Service User Guide sets out the criteria and procedure for admission to Eastridge Manor, which describes the importance of an assessment “to ensure individual needs can be met by the resources available at the home” and encourages prospective residents to visit the home. During the morning of the visit a prospective resident arrived at the home to spend the remainder of the day with the residents and staff, so that the prospective resident could become familiar with the other residents, the layout of the property and staff. A person visiting their relative living at the home described how they had visited a number of homes before Eastridge Manor to see what facilities were being offered. They had chosen this home because it felt “more homely”. A person writing to the inspector about their experience of the home for their relative said, “ I visited the home. I asked the manager to assess my mother. This was done in a professional way”. It was then agreed that the prospective residents should stay for a trail period and that she settled well. One resident who spoke to the inspector in the privacy of their room said that their daughter had chosen the home for them and then they had brought them along to have a look before they moved in. Eastridge Manor does not provide intermediate care but does offer periods of respite care. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plan systems being introduced by the current providers give clear information to assist with all aspects of health, personal and social care needs. Resident’s healthcare needs are being addressed by healthcare professionals to make sure that these identified needs are being met. The home demonstrated satisfactory medication handling and some areas for improvement were discussed. Staff respect the privacy and dignity of residents, making sure that residents are treated as individuals. EVIDENCE: The home is currently adopting a new care planning system already used in other care homes within the organisation. The plans sampled at this visit Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 12 included the records of two people who had recently moved into the home and two people who had lived at the home for over a year. All four plans had been transferred to the new care planning system and were observed to be comprehensive and based on an assessment of needs carried out prior to moving into the home. Risk assessments were observed to be in place to ensure that staff are able to work safely with residents. There are separate records kept which showed that residents have access to normal health care provision, recording the dates of visits by medical professionals such as GP’s. A visiting District Nurse commented that they had been attending a number of residents over the past few years who are registered at one of the two local medical centres. She felt that there was a good system of communication between the surgery and the staff at the home. Records provided to the inspector some weeks prior to this visit to the home showed that residents have access to other professionals such as mental health teams, chiropodists, dentists and opticians. Company medication policies were available to staff. Care plans sampled included a section on medication with guidance for staff. A member of was observed to prepare medicines with reference to medication administration records and was patient and encouraging while a resident was taking medicines; asking if they also wanted the medicine, prescribe to be taken when required. On return to the locked medicine trolley the member of staff made a record of the administration. Handwritten items on medication records corresponded to the dispensing labels, but there was no indication of who had written these. It was clearly recorded, initialled and dated, that a named GP had stopped a medicine. Records of receipt and disposal of medicines were seen. Storage of medicines was in lockable trolleys, which were chained to a wall in the hairdressing salon when not in use. A carer said that medicines, such as in use creams were kept in locked drawers in residents’ rooms. A medicines fridge was not locked and the temperature was not monitored. The manager said that a lock and a thermometer had been ordered through the company. Unwanted medicines were stored in a separate locked cupboard. There was a list of staff authorised to administer medicines. Two members of staff said they had attended a recent medication training session by an external trainer and one was doing a medication module in an NVQ 3 course. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 13 The manager said that she and the head of care had attended a more in depth medication training course. The home had a current agreement for pharmaceutical advice from the supplying pharmacy. A person writing to the inspector about their experience of the home for their relative said “ she was always in her own clothes, care taken to colour coordinate these, her hair was combed, her spectacles never lost, she was clean and appeared much more relaxed. The home never knew when I was going to visit and the standards were always the same”. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a flexible care service, which allows for individual preferences and routines. The social activity programme is flexible to offer variation to daily living. Meals are well managed; there is a variety of food available so that residents and offer have a choice about what they eat. EVIDENCE: Eastridge Manor is in a peaceful setting with extensive gardens, which staff encourage residents to use in suitable weather. It was observed in care plans that time had been taken to write to resident’s families and advocates to secure their agreement to escorted walks in the garden and occasional escorted outings. Care plans also recorded the interests of residents prior to moving into the home. One resident had been a church organist and still liked to play the Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 15 organ, which the care plan stated, should be encouraged. After dinner a member of staff was heard to ask this person if they wanted to play their organ. The organ recital, which followed, was then appreciated by residents who wanted to listen. Photographs on display in the entrance porch record events and activities which residents have taken part in. Cards being made for Christmas were on display in the conservatory. A visitor spoken with commented that it is a lovely home there are activities but their relative chooses not to take part. The visitor’s book records regular visitors to the home and the visitor spoken with felt that they were made to feel welcome during their visits. The resident’s agreement/contract sets out the arrangement for unrestricted visiting but discourages visiting at busy periods such as before 10am. An inspector joined residents for the main meal of the day, which was shepherds pie, carrots and leeks followed by pears and chocolate custard. The meal was served in a pleasant dining room overlooking the large garden, at a smaller dining area in the conservatory or if people preferred they could have their meal in their room. Some residents took longer than others to eat their meal but staff were very patient with residents, offering assistance when people were struggling and enabling others to take as long as they wanted. Menus provide prior to the visit showed that a variety of food is offered with alternatives available. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 16 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): 16,19 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear and enables those using the service to have the confidence that their complaint will be responded to within a maximum of 28 days. The homes adult protection procedure is clear and residents are protected by arrangements in place to protect them from being placed at risk of harm or abuse. EVIDENCE: The complaints procedure is included in the Service User Guide and on display in the home. It is clear and gives an assurance that “all complaints will be dealt with within 28 days”. Two complaints had been recorded in the complaints record book, which had been investigated by the manager with satisfactory outcomes recorded. The home has an Adult Protection policy, which was provided to the inspector prior to the visit. It is used in conjunction with the West Sussex Multi Disciplinary Adult Protection procedures. Training records showed that the home is providing adult protection training. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 17 No Adult protection issues have come to the attention of the inspector Eastridge Manor since it was registered with the current providers. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an ongoing maintenance plan so that the home is well maintained and the decoration of the home remains of a good standard, providing residents with a homely, safe, comfortable environment. Bedrooms are comfortable and meet the needs of the residents. Residents are encouraged to contribute to making their bedrooms their own by having their own personal possessions around them EVIDENCE: Eastridge Manor has been extended and refurbished to a high standard. It is a detached property set in its own extensive grounds in the rural village of Wineham in West Sussex. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 19 Private accommodation is provided in twenty-nine single rooms of which twenty-seven have en suite facilities. There are also two double rooms, which can be used as either double or single rooms. Both double rooms have en suite facilities. Communal accommodation consists of two lounges, a dining room, a conservatory and a large comfortable hall where residents like to sit on the armchairs and sofa listening to music. There is also a sitting area in the gallery above the main hallway which looks out on to the grounds through large picture windows. On the day of this unannounced visit the home was observed to be clean, reasonably tidy and well maintained. There is a maintenance book, which records what repairs and maintenance has been carried out. Eleven bedrooms were sampled at random, and found to be well maintained, clean and free from odour. Residents have been encouraged to contribute to making their bedrooms their own by having their own personal possessions around them. A resident spoken with in the privacy of their room said, “I like my room, its cosy”. Bathrooms and toilets visited at this visit were observed to be clean and well equipped. Residents can access all parts of the communal areas and the majority of private accommodation by the use of ramps or lifts. The limited access to three bedrooms on the first floor is described in the Statement of Purpose and Service User Guide so that prospective residents know that they will need to be fully mobile to be able to accommodate these three rooms. Information provided by the manager prior to the visit to the home and records viewed during the visit, showed regular maintenance of equipment and services. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are meeting the needs of the residents living at the home. Recruitment procedures safeguard and protect residents at the home. Staff have taken part in training and Vocational Qualifications to maintain their skills and ensure that residents are safe. EVIDENCE: Duty rotas were observed during the visit to the home. A system is in operation, which ensures that staff are deployed effectively across the home assigned to different groups of residents. During the visit it was observed that staff were readily available to attend to residents needs. A visitor spoken with commented that “staff are very kind” and a resident when asked about the staff said “ oh yes we get on very well”. Another residents spoken with in their bedroom said, “ the staff are very good. They offer to help but I can wash and shave myself”. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 21 Staff records and information provided by the manager of the home prior to the visit about the qualifications of staff show that 50 of the staff have an NVQ qualification at level two or above. The records of three staff were examined during the visit to see if recruitment policies of the home were being followed and to ensure that those employed had Criminal Record Bureau Clearance and Protection of Vulnerable Adult Clearance. All records seen included a job description, evidence of identity, two references and evidence that CRB and POVA or POVA first clearance had been received. A staff-training programme gives the staff the opportunity to maintain and develop their skills. Training records and information provided by the manager show that recent training includes: Moving and Handling, First Aid, Adult Protection, Dementia Care, Diabetic Care, Continence, Pressure area Care, Infection Control, Food Hygiene and Stand aid/Hoist training. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed providing leadership and guidance for staff. The views of resident’s families and friends are not formally being sought to measure how successful the home is at meeting its aims and objectives and the statement of purpose of the home Systems for handing residents monies ensure that residents are assured that their financial interests are being safeguarded. Eastridge Manor provides a safe environment for residents to live in. EVIDENCE: Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 23 The manager has the required experience to manage the home and has almost completed the N.V.Q Level 4 Registered Managers award. She is able demonstrate that she has continued to improve her own knowledge, skills and competence by undertaking training relevant to her role. The organisation has a Quality Assurance Policy but this has not been put into operation at Eastridge Manor. A statutory requirement has been made that the providers must carry out a formal quality assurance process in accordance with the organisations own Quality Assurance policy to measure its success in meeting the aims and objectives of the home and its statement of purpose. The manager was unable to provide evidence that the providers are meeting their obligations to provide her with reports about their visits to the home. A statutory requirement has been made that the providers carry out unannounced visits and provide the manager with a report of the visit. Supervision records were observed to be present in the staff records viewed at this visit and staff spoken with confirmed that they are supervised. The manager told the inspector that relatives are invoiced directly for any expenses, which are not covered by the fees paid. This avoids holding monies on behalf of residents. All records viewed at this visit were in good order and had been maintained up to the date of the visit. No health and safety issues came to the attention of the inspector at this visit except for one bedroom door, which did not close properly. The inspector was shown the recent Fire Risk Assessment carried out at the home, which had identified the risk, with an outcome to either replace or re-hang the door. Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 4 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 4 3 3 4 3 3 4 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 3 2 x 3 3 3 3 Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP9 Regulation 13.2 Requirement The medicines fridge must be locked and the temperature monitored, to ensure that medicines are secure and stored at the correct temperature. The providers must carry out a formal quality assurance process in accordance with the organisations own Quality Assurance policy to measure its success in meeting the aims and objectives of the home and its statement of purpose. As part of the providers on going monitoring of the home reports (Regulation 26) must be provided to the manager of the home which record the outcome to the visit and cover all matters detailed in Regulation 26.4. Reports must be available at the home for sight by any representative of CSCI. Timescale for action 14/12/06 2 OP33 24 01/01/07 3 OP33 26 01/01/07 Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 26 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 OP9 Good Practice Recommendations When it is necessary to write new medicines on the medication administration record the entry should be signed and dated (including a witness when this is possible.) Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southampton HO 4th Floor, Overline House Blechynden Terrace Southampton Hampshire SO15 1GW 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 Eastridge Manor DS0000065674.V307515.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!