Inspection on 15/07/05 for Golborne House

This inspection was carried out on 15th July 2005.

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

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

Other inspections for this house

Golborne House 16/10/08

Golborne House 26/09/06

Golborne House 10/02/06

Golborne House 14/10/04

Golborne House 06/05/04

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

CARE HOMES FOR OLDER PEOPLE GOLBORNE HOUSE Derby Road Golborne Wigan WA3 3JL Lead Inspector Kath Smethurst Unannounced 15 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Golborne House Address Derby Road Golborne Warrington WA3 3JL 01942 726945 01942 276686 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CLS Care Services Limited Mrs Gillian Sara Menquy CRH Care Home only 40 Category(ies) of DE(E) Dementia over 65 years (1) registration, with number OP Old Age (40) of places PD(E) Physical Disability over 65 years (8) GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include:up to 40 service users in the category of OP (Older People) up to 8 service users in the category of PD(E) (Physical Disability over 65) 2. Within the maximum number registered there can be up to 1 temporary DE(E) for specific service user. The conditions to revert back to the original once this service user has left the home. 3. The service should employ a suitably qualified and experienced Manager who is registered by the CSCI. Date of last inspection 14 October 2004. Brief Description of the Service: Golborne House is a two-storey building with pleasant garden areas, situated in the middle of a housing estate, half a mile from Golborne town centre. It is close to shops and other local facilities and is well served by public transport. The Home is spacious with several lounges and dining areas. All bedrooms are single and five have an ensuite toilet facility. There are ample communal toilets and bathrooms situated throughout the home. Golborne House provides personal care and support for forty people over the age of sixty five years. The home is owned and managed by CLS Care Services Limited who have 40 plus homes around Cheshire and the Wigan area. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.30 am. It took place over six hours during the morning and afternoon. The pharmacist inspector visited the home on the 3 June 2005 and checked medication records. The inspector looked around some but not all of the home. Records were looked at and the inspector ate the meal served to residents at lunchtime. The staff handover was also observed. To get more information about the home the inspector spoke to six residents, one visitor, four staff and the senior member of staff on duty. What the service does well: What has improved since the last inspection? More staff now work in the mornings so residents don’t have to wait too long for help when they want to get up. Residents said they were very pleased with this improvement. Good progress has been made by the manager to make sure that the things, which needed improving from the last inspection, have been done. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 6 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. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 4. Terms and conditions of residence/contracts are issued, which ensures residents/representatives have detailed information about what their rights are. The admission procedure is good and systems are in place to ensure proper assessments are completed prior to people moving in. The manager and staff demonstrated a high level of commitment to ensuring the needs of residents were being met. EVIDENCE: Contracts are kept residents financial files. A detailed terms and conditions of residence is in place and each new resident is given a copy when they come to live at the home. A sample of contracts was examined to find they had been signed and agreed by residents or their carers. Those residents who have their care paid for by local authorities have a service delivery agreement. The local authority contract contains broader terms and conditions of residence. Inspection of the records of four residents showed an assessment of care needs had been completed and where applicable social work assessments had been taken note off. The assessment document was detailed and included information relating to physical needs and personal preferences. All GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 9 assessment documents had been signed and agreed by residents or their representatives. Two residents described how staff asked about there needs and preferences prior to and on admission. Staff spoken to were aware of the importance of undertaking pre-admission assessments in order important and significant information is recorded. All residents spoken to felt their needs were being met. During the inspection staff were seen to be attentive to the needs of residents and knew what care was needed. The manager had identified where staff required training and had arranged training sessions for staff in different aspects of care such as moving and handling, first aid, medication, dementia care and National Vocational Qualifications. Where it was identified that residents had specialist health needs, health care professionals were involved. For example general practitioners, district nurses, optician, chiropodist and the continence advisor. The staff handover was observed where staff on coming on duty were given details of significant events relating to residents. It was pleasing to note that all staff felt able to contribute to discussions. It was also evident they were very knowledgeable about the residents care needs and well being. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Care plans were detailed, up to date and provided staff with the information they need when delivering care. Health care needs were well met with evidence of multi disciplinary working taking place. The systems for the administration of medication were in the main satisfactory, but assessments for those residents who self-administer had not always been completed which could place them at risk. Personal support is offered in such a way as to promote residents privacy. EVIDENCE: Four care plans were examined. All contained comprehensive information relating to residents personal, social and health care needs. Daily entries in care notes were completed in all the plans examined. The plans were easy to read, had been regularly reviewed and set out clear guidance for staff to take when providing care. There was written evidence that the plans had been signed and agreed by either the residents or their representatives. The care plans examined contained some very good information in respect to residents past lives, needs, likes/dislikes and chosen lifestyle. For example one read, “I do not want the night staff to check me every hour as this disturbs me” a second “I am private and like my own company” a third “ I like my supper in GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 11 my bedroom about 8pm” and “ I like my bedroom door locked”. The residents and visitor spoken to were all very complimentary about the standard of care provided. For example a visitor described the care as being “ very good”. Detailed risk assessments were in place in each of the files inspected. They covered areas such as nutrition, pressure areas and moving and handling. All had been reviewed and updated on a regular basis. The health care needs of residents were being met. For example a visitor was very pleased with the improvement in her friends health since she came to live at the home. Individual care records inspected showed evidence of visits from General Practitioners, chiropodist, optician and district nurses. The CSCI pharmacist undertook an inspection of the homes medication policies and procedures in June and in the main they were found to be satisfactory. Medication storage was secure and orderly and medication to be returned to the pharmacy was clearly segregated from that in use. Trained carers administer all other medication. A range of homely remedies (agreed with the supplying pharmacist) is available within the home. It is advised that administration of these is recorded on the Medication Administration Records (MARs). As at the previous inspection, four residents are supported to self-administer some of their prescribed medication. One resident administers some tablets. Arrangements had been made with the supplying pharmacist for these tablets to be place in a suitable monitored dosage system (MDS). Assessment of safe self-administration is recorded. One resident has recently begun to self-administer an inhaler but assessment had not yet been documented. An assessment must be completed for all selfadministration including, inhalers and creams. The pre-printed MAR examined were generally up to date and had been regularly audited by the manager. Where hand written entries were made they were found not to have been checked and countersigned. This is recommended to reduce the risk of transcription errors. Separate records were maintained for controlled drug handling, but where residents did not require these an entry indicating this was not made on the MAR sheet. Although entries for nonadministration are not required in the controlled drug register, they should be made on the MAR sheet. Records of medication received into and leaving the home had been maintained. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 12 Anecdotal evidence from residents indicated that staff respected their privacy and dignity. During the inspection staff were seen to treat residents with respect and consideration, were attentive to individual needs and discreet when providing assistance. Written evidence in care plans showed that resident’s needs in respect to dignity were considered important. For example in respect of personal appearance. One care plan instructed staff that a resident “ liked to look smart” a second “ I prefer my nails long” and a third “ I like my hair done weekly”. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15. Dietary needs are well met with a balanced and varied selection of food available that meets resident’s tastes and choices. EVIDENCE: Menus were examined and were found to be well balanced and nutritious. Menus are compiled centrally for all CLS establishments. Discussion with the cook indicated she was able to adapt menus to suit resident’s preferences. A choice is offered at every meal. However it was noted that the alternative to the main meal was the same all week. While it appears residents have no complaints, this it could restrict the diet if a resident didn’t like the either the main meal or the alternative. The manager is therefore advised to undertake a review of the range of alternatives offered in order to provide more variety. Breakfast is served on a flexible basis, the main meal being served at teatime and a light lunch served at around midday. Meals are eaten in the main dining room or several smaller lounge/diners throughout the Home. The dining areas were clean and efforts had been made to give an air of domesticity. Dining tables were tastefully set with linen tablecloths and floral displays so ensuring a congenial atmosphere. Menus are also displayed. The inspector sampled the food served at lunchtime. Lunch on the day of inspection consisted of soup and sandwiches. A good selection of sandwich fillings was available. The meal was well presented, in sufficient quantities and tasted good. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 14 The inspection took place during a period of very hot weather so it was pleasing to note that cold drinks were readily available and staff were observed regularly asking residents if they would like a drink. Special occasions are celebrated in the home for example birthdays and anniversaries. One resident had recently celebrated her golden wedding anniversary a buffet and party was arranged by the homes staff. A number of residents living in the home were spoken to and everyone who commented said the food was good. All expressed satisfaction with the quantity and quality of the meals provided. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16. The home has a satisfactory complaints system with evidence that residents feel their views are listened to and acted upon. EVIDENCE: A detailed complaints procedure is in place. Details of how to complain are contained in the “Service User Guide” which each resident has a copy of. A system is in place for recording complaints. The homes complaints book was examined and showed three complaints had been logged since the last inspection in October 2005. The complaints made directly to the home related to cold food, the lighting and a commode not being emptied. There was written evidence these complaints had been thoroughly investigated including details of the steps taken to rectify the issues and a copy of the report sent to the complainant. All the concerns raised had been resolved to the complainant’s satisfaction. No formal complaints have been received by the CSCI over the past year. Anecdotal evidence from residents indicated they felt able to approach staff with any concerns and these would be taken seriously. None of the residents had made a complaint but all indicated they were aware of how to do so if the need arose. In addition to the formal complaints system the home holds regular residents meetings. A “Customer Feedback Log” is also provided for residents and their relatives to make comments about the home. Examination of the minutes of the last residents meeting held on the 18 April 2005 indicated that residents had no complaints about the care provided or GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 16 organisation of life in the home. The customer feedback log had three entries all of which made positive comments about the home. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 and 26. The standard of the environment within this home is good providing residents with an attractive, homely and clean place to live. EVIDENCE: Golborne House is well maintained internally and externally. Nevertheless improvements to the fabric of the building continue. For example redecoration of resident’s private space and communal areas. In the main standards are good but it was noted that the wallpaper in some of the corridors is damaged. This needs to be addressed as part of the planned programme of renewal and maintenance to ensure standards in the home don’t fall below an acceptable standard. The Home is spacious with several lounge and dining areas. These areas are furnished with good quality items. Ornaments, fireplaces, pictures and flowers enhance the homeliness of these areas. The garden areas are tidy, well maintained, safe, secure and accessible for residents. Residents and visitors GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 18 spoken to made no adverse comments about environmental standards in the home. All areas of the home were clean and odour free. Residents and a visitor commented positively about the cleanliness of the home. Policies and procedures were in place with regard to infection control. Staff were provided with protective aprons and disposable gloves. Liquid soap and paper towels were provided near to hand washing facilities. Staff were observed to be maintaining good hygienic practices. All laundry is undertaken on site and residents spoken to had no complaints about the standard of laundry service provided. Although functional the laundry is quite small. The senior member of staff on duty advised that discussion had taken place about enlarging the laundry but no decision had been made. Given the size of the home it would be beneficial if the facility was extended and this is recommended. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. Staff morale is high resulting in a committed and enthusiastic workforce, this ensures a consistent standard of care for people living in the home, but staffing levels need to be reviewed to ensure care needs are not compromised. Recruitment procedures for staff are robust which ensures people living in the home are protected. A comprehensive training programme is in place, which equips staff with the skills, and knowledge to meet residents assessed needs. EVIDENCE: On the day of inspection sufficient staff were on duty to meet residents care needs. During the visit staff were observed to respond speedily to requests for assistance made by residents and also spent time socialising with them. Examination of staff rotas showed that when staff were on leave or off sick absences were covered. The Manager works on a supernumery basis. Domestic and catering staff support care staff seven days a week. Many of the staff have worked at the home for a considerable time and staff turnover is low. It was clear from the comments of staff that they liked working at the home. For example one member of staff said that CLS “is a good company to work for”. Since the last inspection staffing levels in the morning have been increased. Staff said this had improved the care provided for residents. For example they could respond more quickly to residents requests for assistance when they wished to get up in the morning. Examination of the minutes of the last residents meeting showed they had noticed the increase and had made positive comments about the improvement in staff ratios. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 20 Comments from staff indicated that additional staff in the afternoon and evening would be beneficial. Currently in the evening and at weekends care team leader carry out administrative and supervisory duties in addition to providing hands on care. These duties could at times take care team leaders away from providing direct care to residents. While this situation does not appear to have compromised resident’s care, staff ratios at these times need to be kept under review. There are only two members of staff on duty each night to assist forty residents to bed and support them throughout the night. Given the layout of the building and dependency levels of residents this may not be sufficient. In previous inspections assurances were given that the number of staff at night and would be increased if necessary. Nevertheless a review needs to be undertaken to ensure ratios at night are sufficient. The files of four staff employed indicated that all necessary recruitment checks had been undertaken. All staff files examined contained: written application forms, 2 references, Criminal Records Bureau (CRB) check and verification of identification. Residents spoken to said that staff looked after them well. A comprehensive staff development programme is in place and records of training are maintained. There was evidence that new staff undertake induction training that meets the National Training Organisation (NTO) specification following which foundation training is undertaken. All grades of staff have a training profile, which identifies training needs. Ongoing training is available and there is ample evidence that these opportunities are taken up. Recent courses undertaken include food hygiene, moving and handling, first aid, medication, health and safety, dementia care and National Vocational Qualifications (NVQ). It was also pleasing to note that training opportunities are made available to catering and domestic staff. For example all domestic staff have attained relevant NVQ awards. Staff who commented confirmed that training was encouraged and widely available. One member of staff described the training as being “very good”. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38. A satisfactory accounting system was in place, which protected resident’s interests. Health and safety practices are satisfactory providing a safe environment for people living and working at the home. EVIDENCE: The home has a satisfactory accounting system in place. The senior member of staff on duty could determine exactly how much money the home was holding for each resident. The Home looks after small amounts of resident’s personal allowances. Detailed computer and paper records are held of all transactions. All monies held for safekeeping are kept individually. A record is kept of monies credited and debited and receipts were obtained for financial transactions. Secure facilities are provided for the safe keeping of money. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 22 Health and safety issues were found to be satisfactory. Policies and procedures are in place and cover a range of topics linked to health and safety. Documentary evidence was available of staff having completed health and safety training including safe moving and handling techniques and first aid. Staff spoken to also confirmed this. All accidents and incidents had been recorded and reported correctly. Records examined provided evidence of regular inspections and maintenance checks of equipment and the building undertaken by external contractors, so ensuring the safety of both residents and staff. Fire safety records showed that that all fire tests and maintenance procedures had been undertaken regularly. Records also indicated that fire drills and instruction had taken place at frequent intervals. GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x 3 x x 3 GOLBORNE HOUSE F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 Requirement Self administration of medication must be assessed and supported in accordance with the homes policies and procedures. The corridors with damaged wallpaper must be redecorated. To ensure staffing levels at night are sufficient a review of ratios must be undertaken. Details to be forwarded to the CSCI Timescale for action 30 June 2005 31 January 2006 31 August 2005 2. 3. 19 27 16 & 23 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 9 9 15 26 27 Good Practice Recommendations Hand written MAR entries should be signed,checked and countersigned. The criteria defining the use of when required medicines should be recorded. Consideration should be given to providing more varied alternatives to the main meal. Consideration should be given to enlarging the laundry area. Consideration should be given to providing an additional member of staff at night. F56 F06 S5735 Golborne House V238546 150705 Stage 4.doc Version 1.40 Page 25 GOLBORNE HOUSE Commission for Social Care Inspection Turton Suite, Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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