Inspection on 15/11/06 for Friars Lodge

This inspection was carried out on 15th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Friars Lodge 04/08/09

Friars Lodge 22/09/08

Friars Lodge 28/09/07

Friars Lodge 01/12/05

Friars Lodge 09/08/05

Friars Lodge 09/03/05

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

CARE HOMES FOR OLDER PEOPLE Friars Lodge 18 Priory Road Dunstable Bedfordshire LU5 4HR Lead Inspector Sally Snelson Unannounced Inspection 15th November 2006 08:35 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 Friars Lodge DS0000062259.V304650.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. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Friars Lodge Address 18 Priory Road Dunstable Bedfordshire LU5 4HR 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) 01582 668494 F/P 01582 668494 Friars Lodge Ltd Vacant Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20), of places Physical disability over 65 years of age (20) Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: Friars Lodge was a private residential home, registered to provide for twenty older people, some of whom may have physical disabilities and/or dementia. The registration for physical disabilities was not applicable because the home was not adapted to provide for service users under this category. Existing service users who had mobility and similar needs associated with old age could be accommodated under the category for old age (OP). Ownership of the home transferred to Friars Lodge Ltd towards the end of 2004. The manager was appointed at that time. The directors of the new ownership were established care home providers in the vicinity. The home was located in a pleasant residential area of Dunstable within close proximity to the Priory and the towns amenities. The building provided a comfortable environment. The bedrooms were distributed on three floors that were accessible by staircases and a newly installed shaft lift. Toilets and adapted bathing facilities were located for convenient access throughout the building. A large lounge/diner and a small visitors/quiet lounge were situated on the ground floor. The lounge overlooked an established and well-maintained garden to the rear of the property. Parking was provided for a few vehicles to the front of the building. There was some on road parking close to the home. Fees for the home are between £425 and £530 a week depending on the room provided. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted by Sally Snelson, Regulation Inspector and took place from 8.35 am on the 16th November 2006. During the inspection a number of the 18 service users were spoken to, as were visitors in to the home and staff. The care of three of the service users was tracked in detail. This meant that their documented care was compared to the care they were receiving and needed. The home had been sent a pre-inspection questionnaire 14.07.06. This had not been returned and the manager was not aware of this document so it was to be re-sent and once completed would provide information for further inspections. The manager was present throughout the inspection and the owner Mr Janes took the inspector on a tour of the premises. The inspector would like to thank staff and service users for the welcome into the home and the time they gave to the inspection process. What the service does well: The home provided service users with a homely environment in which to live. The home was well furnished and clean despite staff reporting that the vacuum cleaner had broken and they were waiting for a replacement. The home provided good positive links with the local community as most of the service users come from the local area. One service user said “it is lovely here because there are people about all the time and I have a lovely garden to look at which fulfils a lot in me”. Community nurses GP’s and other health staff were used appropriately for advice and support. There was a pleasant atmosphere in the home and it was apparent that staff enjoyed their work and got on with each other. Staff spent time with service users and made time to speak to them and involve them as they went about their duties. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 6 Mealtimes were sociable occasions. The dining tables were neatly laid and vegetables were served to the service users from terrines. The menu had recently been updated and those service users spoken to were happy with the choices they were offered at mealtimes. One said “the pastry is so good it melts in my mouth” What has improved since the last inspection? What they could do better: There was still a need for care plans and other documentation to be written in more detail and to be regularly reviewed and updated. Documentation must be taken seriously as this is often the only evidence that episodes of care have been provided. If the home wishes to retain their registration to accommodate service users with dementia the laundry door must be secured, all staff must receive training in dementia awareness and the environment and the activities must be suitable for service users with this condition. At the time of the inspection none of the service users had severe dementia but their conditions could deteriorate and their needs become greater. Staff must receive regular supervision and the home’s training plan should be linked to this. There should also be more robust systems in place to assess customer satisfaction. The did not encourage service users to have any money of their own, even if it was held by the home on behalf of the service user. This takes away some element of choice and independence from service users. The inspector was Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 7 particularly conce4rned about the practice of offering service users 50pence for a collection following a religious service and then billing this cost to the family. 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. Friars Lodge DS0000062259.V304650.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 Friars Lodge DS0000062259.V304650.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. To ensure that the home has the evidence that it can meet the assessed needs of a service user, the pre-admission assessment must be more thoroughly documented. EVIDENCE: The Statement of Purpose had been updated to include the staff changes including the move of the registered manager to another of the current owners homes. However, as the new manager had not yet completed the Commission for Social Care registration process she must not be referred to on any documentation as the registered manager but simply the manager. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 10 The Statement of Purpose included all the headings detailed in schedule 1 of the National Minimum Standards for older people but did not include enough information about making a complaint. The document referred the reader to the complaints procedure but did not outline the expected timescales. Since September 2006 it has been a requirement that the service users guide includes the fees payable. This needs to be addressed in the provided documentation. Many of the service users spoken to stated that they had known about the home because they lived in the local area and knew it had a good reputation. One visitor said that she had looked at other homes for her mother, but felt that Friars Lodge had the most space and was clean. Only one of the files sampled was for a service user who had been admitted to the home under the new management (since 2004). In this file it was difficult to ascertain what documentation had been completed prior to admission and what at the point of admission. The manager indicated what documentation had been used but it was not in sufficient detail to provide evidence as to how the person undertaking the assessment had made the decision that the home could meet the service users needs. This document should include information about where the assessment took place and the source of any additional information. For example if the hospital the family or the placing social worker provided information this information should be referenced to them. Staff were observed to meet the needs of those service users with a diagnosis of dementia but there was limited evidence that all the staff had undertaken training in dementia care. The lack of training could become more evident as a service users dementia became more challenging and their needs more demanding. Service users were offered an initial trial period at the home. A service user who had not been at the home very long said “Now I have settled my children can move into my house”. The inspector believed this to mean that she had made the choice to stay at the home. At the time of the inspection Friars Lodge did not offer intermediate care. During the tour of the building the owner expressed an interest in using one of the bedrooms to provide respite care. The Statement of Purpose would need to be altered to reflect this change if it happened. Friars Lodge DS0000062259.V304650.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. To ensure that all the needs of the service users are meet care plans should be written in more detail. Throughout the inspection service users were observed being treated with dignity and respect. EVIDENCE: In the care files sampled there was evidence that care plans had been written reviewed and altered. However this process needed to be tightened up. For example care plans were not routinely reviewed monthly. A service user whose needs had changed due to hospitalisation had an updated care plan but a service user who had initially been assessed to self-medicate but now needed Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 12 to have her medication administered by staff still had self-medicating on her care plan. Social care plans were stored as part of the activity book. These would benefit from being more comprehensive and including more information about the service users past hobbies and interests and how the service user responded to any activities provided. Daily record sheets were clearly written and there was evidence that community health professionals were involved in an appropriate and timely fashion. Community health staff were responsible for interpreting Waterlow scores and suggesting pressure relieving equipment. On the day of the inspection the continence advisor was visiting to provide support. The staff confirmed that they had a good relationship with the community nurses who visited the home. Risk assessments were in place but again these should be expanded to include exact plans to reduce risk. Medication charts were sampled and were correctly completed. For example the receipt of the medication into the home was recorded and medication was signed for when it was administered. Staff were not in the habit of recording variable doses. When the chart stated one or two tablets they must record how many were given. One service user prescribed medication for the night was given during the day. The deputy manager stated that the GP had made the change but there was no documentation to support this. Also staff should not be administering medication that had a ‘’to be given as directed’ instruction. The pharmacist must include clear directions on the label. Staff were recording the daily temperature of the medication fridge but not the cupboard that the medication trolley was stored in despite there being a thermometer in the room. On the day of the inspection, which was not a particular hot day, the temp was 29 degrees C. Most medication have a warning on the packaging that they should not be stored at temperatures exceeding 25 degrees C. It was noted that the service users privacy and dignity was respected at all times. Staff spoke quietly to service users and encouraged them to visit the toilet frequently with minimal fuss. All of the service users were well dressed and wearing clothes that had been carefully laundered, many wore items of jewellery and make-up. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were stimulated with a variety of activities that were provided by staff and visiting groups and individuals. EVIDENCE: The home had good links with the local community and had visits from various church groups to provide religious services and concerts. It was apparent that friends and relatives were welcomed into the home at any time. One visitor said “I looked at a lot of homes, some were too big. Here they are stimulated mentally as well as looked after”. Service users reported doing various art and craft activities in addition to bingo and music and enjoying concerts. Staff, although very busy, appeared to have time to talk to service users as they went about their work. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 14 The inspection coincided with the State opening of parliament. The manager suggested some of the service users may like to watch it on the TV in the lounge. She took time to explain to them what was going on and what they were watching. At the start of the inspection it was noted that service users were having their breakfast when and where they choose. For example some had a tray in their bedroom while others had their breakfast at a dining table when they got up. On the day of the inspection the regular cook was on annual leave and a relief cook, who worked across all the homes owned by Mr Janes was doing the cooking. Service users were offered the choice of fish in sauce or pork chop with vegetables followed by cherry pie and custard or peaches and cream. The meals were attractively presented and vegetables were served at the table. Hot and cold drinks were available throughout the day and staff actively encouraged fluids. Most service users sat at dining tables for their meal. Mealtimes were a sociable relaxes occasion. The previous manager had introduced new menu which the service users were not as happy with. The new manager had recently reviewed these with the service users and made a number of changes. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users should be safeguarded as all staff had been trained in recognising and reporting abuse since the last inspection. EVIDENCE: The complaints file included clear guidance about making and responding to complaints, but it was not personalised to Friars Lodge. In the complaints file there were four complaints, one from a member of staff following the loss of some money, two from relatives about care issues and one from a neighbour. There was evidence of the investigation methodology used to address these complaints and the letters sent to the complainants in response to the concerns raised. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 16 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): 19,20,21,23,24, and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Friars Lodge provided service users with a homely, clean environment in which to live. This judgement would be excellent if the home did not have a registration for dementia care. EVIDENCE: The home has always been fitted and furnished to a high standard. The new owner had ensured that all the radiators were covered to prevent accidents and had fitted a shaft lift to all floors. The main lounge was large and had a dedicated dining area. The majority of the service users choose to sit at one end of the lounge despite their being chairs in other areas. The large lounge Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 17 allowed service users to get up and walk about if they required. There was a small quiet area off the lounge that can be used by service users to entertain their visitors. Many of the service users have been redecorated and wherever possible en-site facilities have been fitted. These en-suites have been finished to a high standard. In addition to the lounge/diner and quiet room Friars Lodge had a hairdressers room, a kitchen and laundry facilities. Service users were encouraged and supported to personalise their bedrooms with the addition of small items of furniture and objects from home. Since the last inspection all service users bedroom doors had been fitted with a lock and they had been supplied with a lockable box in which to keep valuables. At the time of the inspection two service users occupied only one of the two double rooms. The inspector spoke to one of the service users who shared and she explained there were no problems and she had been sharing for three and a half years and when offered a single room she had declined. She reported that a screen divided the bedroom when they were in bed, and as the other lady was deaf there was little communication between them. The manager was aware that any future admissions into shared space must have the opportunity to make an informed decision to share with that particular service user. A recent environmental inspection of the kitchen had been satisfactory with a requirement that the metal tables be earthed now that the freezers had been moved to an area outside the main kitchen. The laundry had been made safer for the staff working in it by removing the need to go up and down steps. The door of the laundry area could be assessed by service users and needed to be secured as there were open packets of detergent on the floor which could be ingested by a service user with dementia. For the home to accommodate service users with a diagnosis of dementia colour coding of doors and labelling should be considered. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures ensured that service users were in safe hands at all times. EVIDENCE: The staff team divided into two, those that had been at the home some years and choose to stay with the new owners, and those who had been employed by the current owners. The staffing levels were considered sufficient for the current needs of the service users. The manager confirmed that agency staff could be used if necessary to cover staff shortages but that many of the staff team were happy to do extra shifts to help. The deputy had taken on the mangers role and a new deputy had been employed. She was a newly qualified nurse but not working as a nurse in the home but brought to the home her experience and expertise. With the exception of the manager and the deputy manager Friars Lodge had four staff with NVQ Level 2 and another four in the process of obtaining it. One senior carer had NVQ level 3. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 19 The staff file of the newest staff member recruited included an induction booklet that had been completed in the first weeks of employment. There was also a questionnaire to support the induction process and check understanding. While sampling staff files it was noted that evidence of a Criminal Record Bureau check was missing from one file. This was tracked to the head office who also kept recruitment records. In another staff file there was evidence the manager had followed up a reference for clarification where the reference had been less than perfect. There was a training programme in place but there was no evidence to suggest how it reflected the individual training needs of the staff team as supervision was not happening as regularly as it should. There was no clear way to check when mandatory training was next due refresher courses were provided within the set timescales. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager worked hard to ensure that the needs of the staff and the service users were met. The home must have systems in place to ensure stakeholder satisfaction. EVIDENCE: The manager, Pamela Mathews, was obviously working very hard to ensure the smooth running of the home. She must now have the confidence to discharge Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 21 some of the management duties to the newly appointed deputy manager. The manager confirmed that the area manager was very supportive and contacted the home daily and visited at least once a month and left a written report on her findings as required by Regulation 26. The manager was doing her Registered Managers Award and her assessor visited during the inspection. She had started the CSCI registration process to become the registered manager. Service users were asked about there satisfaction of the home via questionnaires. For this process to be useful and meet the standard these questionnaires needed to include a wider group of stakeholders, for example district nurses, GP’s and visitors. Then when the questionnaire were completed the outcomes should be reviewed and there should be evidence that they have been used to facilitate the annual development plan. All of the staff had had an annual appraisal since the beginning of the year and were aware of the supervision process as they were supervised, if somewhat irregularly, by the manager. Now that the manager had a deputy in post they planned to allocate the supervision of staff between them and start the New Year with a new supervision timetable. There had only been occasional staff meetings and one relatives meeting since the new providers took over. All the radiators were now covered and fire and other health and safety checks were carried out regularly. The fire officer was due to visit the home for an inspection the day after this inspection. The manager was spoken to after the fire inspection and with the exception of also documenting fire drills as alarm checks she believed it had been a satisfactory inspection. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 22 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 2 X 2 2 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 1 X 3 Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 and 5 Requirement The registered provider must ensure that the Statement of Purpose and the Service Users Guide includes more detailed information about making a complaint,(particularly the timescale in which the complaint can expect a response) and the weekly fees. The pre-admission assessment must be documented in more detail and include all the headings outlined in standard 3.3 All Staff must receive training about the needs of service users with dementia and how these can be best met. (Previous timescale of 30/03/06 had not been completely met but many staff had received training) This requirement also refers to standard 4 The service user’s care plans must be reviewed by care staff in the home at least once a month The registered person must ensure that staff adhere to DS0000062259.V304650.R01.S.doc Timescale for action 01/01/07 2. OP3 14 31/01/07 3. OP30 18(1) (c)(i) 31/03/07 4. 5. OP7 OP9 15 (2) (b) 12 (1) 01/01/07 01/01/07 Friars Lodge Version 5.2 Page 24 6. OP30 18 7. OP33 24(1) 8. OP36 18(2) procedures, for the receipt, recording, storage, handling, administration and disposal of medicines. There must be evidence that the training that staff undertake is linked to their training needs analysis. The home must continually monitor the care provided and use the information from questionnaires to plan and improve future care. All staff must receive a minimum of six supervision sessions a year. 01/01/07 01/01/07 01/01/07 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 OP26 Good Practice Recommendations The laundry room should not be accessible to service users. Friars Lodge DS0000062259.V304650.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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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