Inspection on 21/02/06 for Elmhurst

This inspection was carried out on 21st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elmhurst 14/04/08

Elmhurst 04/04/07

Elmhurst 06/02/07

Elmhurst 19/07/05

Elmhurst 15/03/05

Elmhurst 25/05/04

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

CARE HOMES FOR OLDER PEOPLE Elmhurst Windhill Bishops Stortford Hertfordshire CM23 6NF Lead Inspector Tom Cooper Unannounced Inspection 2:15 21 February 2006 st 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 Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elmhurst Address Windhill Bishops Stortford Hertfordshire CM23 6NF 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) 01279 713100 01279 713161 www.quantumcare.co.uk Quantum Care Limited Mr Peter Meredith Care Home 61 Category(ies) of Dementia - over 65 years of age (61), Learning registration, with number disability over 65 years of age (61), Old age, not of places falling within any other category (61) Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: There are no extra conditions. Date of last inspection 19th July 2005 Brief Description of the Service: Operated by Quantum Care Limited, the voluntary organisation that is the provider with the largest number of care homes in Hertfordshire, Elmhurst is a care home providing accommodation and personal care for up to 61 elderly service users. The home, purpose-built in the late 1990s, is divided into four separate units (one specialising in dementia care) and offers all single bedrooms with en-suite facilities and spacious communal areas in each unit. Elmhurst is situated within walking distance of Bishops Stortford town centre that has a mainline railway station and a wide range of shops and other amenities. There is adequate car parking space in front of the building. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection for the year 2005/6 under the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. The last inspection was carried out on 19th July 2005. The inspection took place over one afternoon/early evening on a weekday. The main purpose of the inspection was to evaluate the service users’ experience of living at the home and to follow up the requirements made at the last inspection. Discussions were held with the manager, many service users in two units and members of staff on duty including two care team managers, and several care assistants. Documentation examined included a sample of service users’ care plans, some staff supervision and training records, the complaints records, medication records, and quality monitoring records. Staff were observed working with service users and a number of residents’ bedrooms and bathrooms were visited. However a formal tour of the premises was not conducted. The inspection indicated that the home was running smoothly, with very contented residents cared for by well trained and highly motivated staff. Two statutory requirements have been made in respect of medication records and risk assessments. What the service does well: The home has good information available to prospective and current residents about the aims of the home and the service promised. Care plan documentation seen made out in the standard Quantum Care format was adequate, conveying a fair level of detail of the individual needs of service users and the actions determined to meet them. Plans seen had been reviewed monthly to ensure they remained up to date. Service users looked well cared for, with tidy hair and fingernails and wearing clean and suitable clothing. All those asked said that staff were mostly very friendly and caring and felt that their personal preferences were respected and taken into account. An excellent rapport was noted between staff and residents, with an exchange of playful banter observed producing a happy atmosphere. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 6 The premises are brightly decorated in domestic styles with comfortable furnishings suitable for elderly people who may have restricted mobility. The unit lounges have very effective lighting that similarly aids the residents. The unitised layout of the home creates living areas of a reasonable scale that can be made homely. All areas inspected were clean and fresh, with no unpleasant smells detected. All service users asked said they liked the home and praised the accommodation, the food provided and said they were happy with the range of activities provided. The home has a robust complaints procedure that is well publicised to residents and their representatives and the home has documentation indicating an effective response to complaints raised. Good systems are in place for the protection of service users, including training in abuse prevention and adult protection. Quantum Care has rigorous recruitment, induction and ongoing training policies and procedures that ensure that any person employed at the home is suitable and competent. Staff files inspected demonstrated that these were being followed. The manager, who has been in post for several years, continues to lead the team effectively, creating a positive and creative environment. Quantum care has an effective quality monitoring process that includes regular monitoring by the senior external managers and the canvassing of the views of service users’ and other interested parties. Feedback received is considered by the management team when planning improvements to the service provided. This is most positive and indicates a commitment to raising standards. What has improved since the last inspection? More progress has been made in implementing a more detailed care plan format that includes greater background and social information about service users. The home now has a specially designated district nurse who visits daily and also provides training for staff on relevant topics such as pressure care. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 7 Funds have been identified to purchase new medication trolleys for storing blister packed medication. The views of service users, relatives and representatives from Hertfordshire Adult Care Services about the quality of the home have been sought using questionnaires. Further redecoration of some areas has been carried out in accordance with the home’s programme of planned maintenance, including new carpeting fitted in one unit. Food stored in unit fridges was labelled and dated. 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. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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 Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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, 5, The home has a statement of purpose and service user’s guide containing the required information so that prospective service users can make an informed choice about whether to move in. Service users are assessed prior to their admission to ensure that the home will be able to meet their needs. Prospective service users and/or their relatives are able to visit the home to access the quality, facilities and suitability of the home prior to making a decision on whether it would suit them. EVIDENCE: It has previously been established that the home has a statement of purpose and a service user’s guide that contain the information required to meet the standard. Staff stated that residents had been given a copy of the service user’s guide. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 10 Service users’ care plan files examined included details of pre-admission assessments undertaken by a senior member of staff. Prospective service users and their relatives/friends generally visit the home prior to admission, spending time looking around, speaking to other service users and perhaps having a meal. Admissions are made subject to a trial period, after which the placement is confirmed if all parties are agreed that the home is suitable. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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 Service user care plans are in place detailing individual health, personal and social care needs and are regularly updated. Service users are involved in care planning. Staff continuously monitor service users’ health and well being and record individual progress. The home has sound medication policies and procedures that should protect service users. However staff must improve the recording of medicines administered to service users as many gaps were found on MAR sheets. Service users feel secure in the home and feel that staff treat them with respect and promote their privacy. EVIDENCE: The individual needs of service users, including health, personal and social care are identified on care plans, with instructions to staff on how to proceed. Care Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 12 plans seen had been reviewed and updated monthly. Service users and where possible relatives participate in the process. However two examples seen had no formal risk assessments in place in respect of pressure sores or falls although a high risk rating had been recorded on the general risk assessment forms on file. These must be completed in all such cases, with clear control measures recorded so that staff know what to do to manage the risks (see requirements). Each resident is registered with a local GP who visits as and when required. District and community nurses visit frequently and their input is well documented. The home now has a specifically allocated district nurse who also provides training for staff in relevant disciplines such as pressure care. Outside health professionals are involved as appropriate, including nutritionist, dentist, optician, audiologist, chiropodist and community psychiatric nurses as required. Service users spoken with felt that staff monitored their condition from day to day and felt they would address any health problems quickly. This made them feel secure. Staff were observed to relate well to residents and engage in some lighthearted banter. This created a relaxed atmosphere. Several service users commented on the friendliness and caring attitude of staff. Medication is securely stored on each unit and there are sound policies and procedures in place for handling, administration and recording that should ensure that service users remain safe. Storage and handling of medication were satisfactory. Code letters were being used properly for incidences where medicines were not administered. However in one unit checked numerous gaps were found on the medication administration record (MAR) sheets, with no explanations of the apparent non-compliances with the GP’s prescriptions written on the reverse. Although the MAR sheets are monitored daily by senior staff, evidently this had not yet promoted consistently good signing by staff. The manager said that all staff were being sent letters instructing them to follow the strict recording rules. A requirement has been made in this report that accurate medication records must be kept. If necessary, in addition to refresher training, disciplinary action could be taken to reinforce the point to staff. Another strategy that could be adopted is that medication recording forms part of the hand-over between shifts and the out going shift remain on duty until the new shift are satisfied with the recording. Service users said they felt treated respectfully by staff, and that they had a good degree of privacy. For example, staff were said always to knock and wait at bedroom doors for permission to enter and service users can choose where to spend time and in whose company. One resident described the staff as “wonderful and so caring”. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15 Service users are able to participate in a range of meaningful activities according to individual choice. Service users can maintain contacts with relatives, friends and are supported by staff as appropriate. The home has good links with the local community. Service users receive a well balanced diet that suits their particular tastes and needs. EVIDENCE: Activities plans were displayed in the units for three days ahead. The home now employs two activities organisers who between them cover during week days. The manager said that they have been devising more individual activities for residents as recommended in the last inspection report. Bingo remains popular as well as card making and cookery. Service users asked said that they were satisfied with the range of activities available although several said they preferred to lead a quiet lifestyle at this stage of their lives. During the inspection service users were seen doing a variety of things, including conversing in the lounges, watching television, entertaining visitors, spending time alone in their rooms and walking up and down corridors. Occasional group Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 14 outings are arrange more often in the summer when the weather is better, for example one group visited Paradise Park near Cheshunt. Staff support service users to maintain contact with family and friends. Service users can receive visitors in private and there are no strict visiting times. There were some visitors in the home during the inspection and those spoken with commented that they were always made to feel welcome. Care plans contain details of individual food preferences and dietary needs. The chef has details of any special dietary requirements. The four-week Quantum Care corporate menu is used. This describes a nutritious and well balanced range of dishes. Staff promote mealtimes as social occasions and service users are allowed eat at a reasonably relaxed pace. Hot and cold drinks are served throughout the day and staff said that snacks are available outside mealtimes on request. Service users asked said that they generally liked the food provided. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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 the following standard(s): 16, 18 Information on how to make a complaint is available and service users and their relatives should feel confident that any complaint they make will be listened to and acted upon by the manager. Adult protection policies and procedures are in place that should ensure the safety of service users. EVIDENCE: Quantum Care has an adequate complaints procedure and information on how to make a complaint is available to service users, relatives and involved professionals in the service user’s guide and elsewhere. Staff spoken with had a good understanding of the principles involved in dealing with a complaint. Only one complaint had been received since the last inspection (the manager explained the home’s proactive approach to resolving informally any grumbles at an early stage). Documentation available demonstrated that the regional manager had responded to the complainant promptly in accordance with the company’s procedure. Many of the residents had dementia and were unable to comment however others said they felt they would be listened to sympathetically by staff were they to complain about something. The manager was aware of the need to learn any lessons from complaints raised and to take action if necessary to change practices in the home to improve the quality of the service. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 16 Quantum Care also has a whistleblowing policy that is available to staff. Individual staff spoken with were aware of this policy and had a fair grasp of their responsibilities under it. A copy of the Hertfordshire inter-agency adult protection procedure is kept in the home. There are also internal policies on adult protection. The topic is covered in the induction programme for staff and also forms part of the NVQ2 course undertaken by many staff. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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 the following standard(s): 19, 26 The building and grounds provide a safe, well maintained and comfortable environment for the service users. The four separate units provide smallish domestic living areas that are homely and suit the needs of people with restricted mobility and confusion. A high standard of cleanliness was evident enabling service users to enjoy pleasant and hygienic living spaces. EVIDENCE: Elmhurst is a modern design, purpose–built in the late nineties with wide corridors, large bedrooms (over 12 square metres) and spacious communal areas. Grabrails, assisted bathing facilities, hoists and pressure care equipment are provided to meet the needs of service users and ensure maximum accessibility and independence. There is a programme of routine maintenance Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 18 organised by the handyperson and a good standard of decoration throughout the building. New carpeting had been fitted throughout one unit. A full tour of the building was not made however the following findings were made: Each unit is appropriately decorated and furnished with chairs suitable for the use of elderly people with restricted mobility. The communal areas are brightly lit for the benefit of the elderly service users and contain numerous personal items belonging to service users that add to the homely presentation. All equipment checked such as hoists and fire extinguishers had been serviced within the last year. The kitchenettes are well organised and provide a very useful facility for making snacks and drinks. Service users’ bedrooms are spacious and contain personal items that reflect individual tastes and interests. All areas seen were clean, tidy and free from unpleasant smells associated with incontinence. Clinical waste was being properly stored in yellow bins. Residents said the laundry service was efficient. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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 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, 29, 30 Staffing levels are adequate to meet service users’ needs and fulfil the aims of the home. The home has rigorous recruitment and staff selection policies and procedures that protect the interests of service users. The home’s induction, supervision and ongoing training policies ensure that staff are adequately trained and competent to do their jobs. EVIDENCE: The staff rota confirmed the manager’s description of the typical staffing levels – normally ten care staff on early shifts and nine on late shifts, with four staff awake covering nights (including a night care manager). This translates to a minimum of two staff in the three basic units and three in the dementia unit. Agency staff are used sparingly (usually workers from one agency who know the home and its routines) because the manager has access to a large list of bank staff. This really helps to promote a consistent standard of care. Ancillary staffing is also good with two cooks and two housekeepers on duty each day. Staff said they felt able to carry out their duties adequately and service users who commented similarly felt that levels were sufficient. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 20 Although this was not specifically inspected on this occasion, a number of staff have completed the NVQ2 course and more are due to start. Quantum Care has rigorous policies for the recruitment and selection of staff and these are followed by the home. The recruitment files for the last two employees were viewed. These contained all the information and documents required by regulation including photographs, Criminal Records Bureau disclosures and references. There was also evidence of a thorough interview process for applicants. New recruits undertake a structured induction programme so that they understand the aims of the home and gain a working knowledge of the company’s policies and procedures. One fairly recently recruited care worker described in detail the elements of the induction she had received, explaining that she was working her way through the foundation training programme. This programme is in line with the National Training Organisation’s guidelines and ensures that staff are capable of working to good care practice standards that fulfil the aims of the home. Mandatory training in food hygiene, first aid, moving and handling, fire safety etc is ongoing. Other recent training courses had included dementia, particularly relevant to this home. The evidence of induction and ongoing training for staff, coupled with the staff/resident interaction observed, supported the conclusion that staff were competent to care for service users. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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 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, 34, 36, 37, 38 The manager is experienced and well qualified to manage the home and provides strong leadership consistent with the ethos of the home. Staff feel appropriately supervised and supported by more senior staff to ensure that the aims of the home are met. All records required by regulation are maintained satisfactorily, with the exception of the medication records and some risk assessments. The home has a health and safety policy and staff follow safe work practices to ensure the establishment is a safe place in which to live and work EVIDENCE: Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 22 The manager is a qualified social worker and has considerable experience of social care in different settings. He is relaxed and confident and provides strong leadership to the team, promoting the high standards of service delivery and care promised in the statement of purpose. Staff and service users said that he was approachable and decisive. The manager is supported by a deputy manager and a number of care team managers who appear to work well together to achieve reasonably consistent care practices in the home. Quantum Care has a quality monitoring system that involves monthly monitoring visits and reports on the conduct of the home made by a senior external manager, and annual surveys of the views of services users, relatives and other interested parties including Hertfordshire Adult Care Services, using questionnaires. The regional manager reviews the responses with the manager and the feedback obtained is considered when planning improvements to the service. Periodic financial audits are also carried out. The company has also created two new quality assurance manager posts to further strengthen the self-assessment process. Staff spoken with said they were well supported by senior colleagues and had regular individual supervision. The manager keeps records of each member of staff’s sessions so that he can track the frequency. The supervisor makes notes of each session on a standard format that includes any actions agreed that are reviewed at subsequent meetings. Each unit holds regular staff meetings. Staff rated communications and teamwork as good. Handovers take place between shifts. Most records examined were well kept and a good standard of documentation was found except as documented earlier in this report. Although the premises were not formally inspected on this occasion, no health and safety hazards were noted in the areas visited. No dangerous substances were noted in kitchens and bathrooms. Fire extinguishers had been serviced in February 2006. Food was stored safely in kitchenette fridges. Staff spoken to confirmed that they had received training in health and safety matters. Adequate supplies of protective clothing such as gloves and aprons were available. Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 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 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 3 2 3 Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 24 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. 2. Standard OP9 OP7 Regulation 17(1)(a) Sch 3 13(4)(c) 13(5)& 13(6) Requirement Accurate records must be kept of all medication administered to service users. Formal risk assessments with clearly documented control measures must be carried out in respect of pressure sores and falls in every case where a high level of risk has been identified. Timescale for action 21/02/06 21/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Elmhurst DS0000019335.V282959.R01.S.doc Version 5.1 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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