CARE HOMES FOR OLDER PEOPLE
Greenways Salisbury Road Darwen Lancashire BB3 1HZ Lead Inspector
Mrs Janet Proctor Unannounced Inspection 30th November 2007 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greenways DS0000034755.V355923.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. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Greenways Address Salisbury Road Darwen Lancashire BB3 1HZ 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) 01254 701954 01254 777574 greenways@blackburn.gov.uk www.blackburn.gov.uk Blackburn with Darwen Social Services Mrs Sandra Reay Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 28 Date of last inspection 17th October 2006 Brief Description of the Service: Greenways is a purpose built home situated in Darwen near to Sunnyhurst Woods. The home is registered for 28 residents - 23 reside in the main area of the home and five are accommodated in an Intermediate Care Unit situated on the 1st floor of the home. The building is surrounded by lawns and patio areas. There is a small area for parking cars at the front of the home. Greenways is a two-storey building but due to the layout of the building the rear elevation is 3 storeys high. Bedrooms are situated on both the ground and first floors, as are bathing and W.C. facilities. On the ground floor there is a large dining room that is used for social events, and there are a number of small lounges. Smokers are catered for. A passenger lift connects the two floors. There is easy access for wheelchair users at the front door. The home is close to a bus route into Darwen Town Centre, and is approximately one mile from the main shopping centre. Prospective residents obtain information about the home through the Statement of Purpose and the Service User’s Guide. The fees charged in November 2007 were £368-00 per week. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Greenways on the 30th November 2007. No additional visits have been made since the previous inspection. On the day of the inspection there were 15 residents in the residential unit and two residents in the Intermediate care unit. Prior to the visit the Registered Manager had submitted information in a preinspection questionnaire. This gave information that was used in the planning of the inspection. Surveys were sent out and were returned by 3 relatives. On the day of the inspection information was obtained from staff records, care records, and policies and procedures. Information was also got from talking to residents, the Manager, staff members and visitors. A tour of the building took place. Wherever possible the views of residents were obtained about their life at the home and their comments are included in the report. What the service does well:
The service ensured that a thorough assessment was undertaken before a prospective resident was admitted to the home. This meant that their needs were known and arrangements could be made to ensure that these were met. Residents spoken to were happy at the home. They said, “I settled in straight away. It’s lovely here and I wouldn’t wish to be anywhere else” and “ It’s very nice here. I’m happy and like it.” The residents were happy with the way that staff cared for them. They said, “The staff are very nice and kind” and “They’re so helpful”. Residents were able to make choices about their daily routines. This meant that they had some control over their lives. A resident said, “I go to bed when I’m ready.” Visitors were welcome to come at any time. This meant that residents could keep contact with their family and friends. A resident said, “I have family in Darwen and they come and visit me. I also have my own phone so they’re only a call away.” The home provided a diet that was varied, nutritious and to the liking of residents. This meant that their nutritional needs were met and they enjoyed their food. Residents said, “The meals we get are very good” and “We had fresh salmon, it was beautiful” Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 6 The home provided a clean and pleasant place for residents to live. There were a variety of areas for residents to sit and relax. This meant that they could have a choice of where they would like to spend their time. A resident said, “I like to sit in this room as there’s no TV, it’s quieter.” The Intermediate Care unit ensured that residents reached their full potential of independence before returning home. This meant that they could be confident that they would be able to cope at home when they were discharged. One resident when asked said, “They asked me some questions about what I could do, and I couldn’t walk then. They told me I was coming here and it would give me more time to get my independence so that I can go back home”. What has improved since the last inspection? What they could do better:
Staff should ensure that documents in the care plan are filed correctly so that the information they contain is readily available. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 7 Staff must make intermittent checks to ensure that residents who selfadminister their medications are doing this correctly. Residents whose bedrooms have exposed hot water pipes should be risk assessed to ensure that these do not present a hazard to their health and well being. There must be a duty roster and a record of whether the roster was actually worked so that there is an accurate record of who has been in the home at any time. The manager should ensure that there are quality assurance systems to monitor the care and services provided at the home. This is so that any shortfalls are identified and can be put right. 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. Greenways DS0000034755.V355923.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 Greenways DS0000034755.V355923.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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had their needs assessed before admission and could be confident that these would be met at the home. The Intermediate Care unit increased the independence and confidence of residents prior to them returning home. EVIDENCE: The records of two residents on the residential unit were examined. They contained copies of assessments completed by health and social care professionals. The Manager visited and assessed prospective residents before offering them a place at the home. A letter was then sent to the prospective resident telling them whether the home could meet their needs or not. A copy of this letter was kept on file. The relative of a resident who had recently been on respite care said, “I looked at a lot of places before choosing this one. Here was definitely the best of the lot. I can’t praise them enough.”
Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 10 The Intermediate Care Unit was a separate unit to that accommodating older people. It had a capacity to take 5 residents, all of which had a single bedroom. There was also a lounge, dining kitchen, assisted bathroom, and Physiotherapy room. Support was provided from a multi-disciplinary team of Carers, Physiotherapist, Occupational Therapist and a District Nurse. Records of two residents on the unit were examined and showed that each had received a thorough needs assessment before and on moving into the home. Greenways DS0000034755.V355923.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans fully identified residents’ needs and told staff how to meet these. Medication practices were safe. Residents felt they were treated with respect. EVIDENCE: The plans of care for two residents on the residential unit were examined. There was a long-term care plan that gave details on the resident’s assessed needs and how these were to be met. There was a plan of care that told staff what the resident could do and what they had to do. This helped to ensure that the care given was consistent. Daily notes were written for each resident. This meant there was information for staff on their daily care, health and condition. A member of staff spoken to said that she read the care plans and thought that the information in the care plans was accurate. There was evidence of consultation with the resident or their relatives. Relatives were invited to the care plan review and these were done monthly.
Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 12 The review gave a statement as what progress had been made that month so it could be seen whether the care being given was appropriate or not. The plans of care included health assessments so that potential problems were identified and acted upon. The District Nurses took responsibility for: pressure sore risk assessments; wound care; and continence assessments. The use of pressure mattresses and cushions was recorded in the care plan. Arrangements were made for medical input as and when required. Two plans of care for residents on the Intermediate Care unit were examined. A long term needs assessment had been completed. Each area was updated with appropriate information so that the care staff could fully meet the resident’s needs. The social aims and objectives section described the resident’s hopes and aims for discharge. The actual care plan highlighted the areas of need and the care instructions described the care to be given by whom, when, and how. Health assessments were done and there was evidence of involvement of a physiotherapist and occupational therapist. One resident’s OT assessment had been misfiled, giving the impression that this had not been done. This had the potential to affect the care planned for this resident. Residents spoken to said, “The health care is wonderful, spot on. I’m walking on crutches now and I made my own lunch yesterday. I was assessed by the Occupational Therapist and he said I was ok to make some of my own meals” and “I have lots of gadgets from the OT and Physiotherapist. They’ve taught me a lot about how to manage when I get home”. The procedures for the control of medications were very thorough. The medications were kept in a separate room and a record of the temperatures of the area and the fridge was kept. There was some good practice seen when checking the medications. This included good records of medications ordered, received, administered and returned. The prescriptions were seen by the home before they were dispensed. There was a photograph of the resident so that they were correctly identified before being given their medication. All residents had given a written authorisation about whether they wished the staff to keep and administer their medications for them. Handwritten entries on the Medication Administration Recording charts had been signed and witnessed. This meant the details were checked as being correct. There was information on the criteria to be used for when ‘as required’ medication was to be given. This meant that they would be given in a consistent manner. The Controlled Drugs were correctly stored and recorded. All staff that administered the medications had received training to do this. This meant that they had the skills and knowledge to do this correctly. On the Intermediate care unit, when the resident first moved into the unit they were asked to sign to agree that care staff will be responsible for their administration. Medications were stored in the resident’s bedrooms in a locked
Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 13 drawers accessed only by a key that is held by senior care staff. Once the resident has been assessed as safe to handle and administer his or her own medications then a drawer key was issued to them. There was a medication reminder chart that showed the resident what medications they were taking and what the medicines were for. Once residents were assessed as responsible to self medicate, staff monitoring stopped. There was no system for checking or monitoring that resident’s were self administering safely. The senior carer said, “We just assume they are doing it right”. The preferred term of address was recorded and used by staff. Residents had access to a telephone. All care was given in private, including visits from other health professionals. Staff were seen to approach residents in a pleasant manner. They made provision for religious needs to be met and were aware of the diverse needs of the residents. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. Residents were able to make choices about their life at the home so that their lifestyle met their preferences. Resident’s social, cultural and recreational needs were met through links with their family and friends being maintained and opportunities to undertake activities within the home. Residents were served a varied and nutritious diet that was to their liking. EVIDENCE: The activities available to residents had been extended. There was a programme on display on the notice board. The programme included a wide variety of subjects and included: Bingo; exercise; walking group; pampering; chat and tea; holistic therapies; letter writing; and relaxation therapy. Some of the activities were done individually and others as group activities. This meant that residents who did not want to join in the group activities had the opportunity to have some social and recreational input. A resident said, “I sometimes join in the activities – there’s enough going on if you want to join in. I like the exercises and bingo best.” Any known family contact was noted in the long-term care plan. There were no restrictions on visitors. Residents said that visitors could come anytime.
Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 15 The known preferred retiring and/or rising were noted in the long-term care plan. Residents spoken to said that they could choose when they went to bed and got up. Staff said that they asked residents and respected choices. One of the relative surveys returned said that the home “Identifies my mother’s need to be as independent as possible.” The choices of food for the next meal was displayed in the dining room. Alternatives were available. The residents were asked what they’d like to eat at lunch and tea so that their choice could be prepared. There was a Cook on duty each day. Records were kept of the food cooked and what each resident had chosen to eat. There was sufficient food in stock including fresh fruit, vegetables and salad. Night staff had access to food items so that they could make snacks if anyone was hungry during the night. Fridge and freezer temperatures and cooking temperatures were kept. There was a residents’ kitchen available so that residents and relatives could make themselves drinks as and when they wanted. The tables were nicely set which contributed to a nice social atmosphere in which meals could be taken. At the start of the inspection care staff were seen to be assisting residents with breakfast in a sensitive manner. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Residents were confident that their concerns would be listened to and acted upon. Residents were protected from abuse and harm. EVIDENCE: There was a procedure for making any complaints in the Service User’s Guide. This told the resident what they had to do and what would happen. No complaints had been made to the home since the last inspection. If any were made, these would be recorded on the appropriate form and the investigation and action taken recorded. No complaints had been made directly to the Commission. Residents and relatives were invited to make written comments about the home and these were kept on file. They had made some very praising comments and these showed that there was a high regard for the staff, facilities and care given. Residents spoken to said that they had no complaints. A resident said, “I’ve never felt the need to complain.” One of the relative surveys returned said that they did not know how to make a complaint. The others said that they did. A comment was made that, “Staff and management are always approachable and appear to be aware of my mother’s requirements.” There were procedures for staff to refer to if they saw, heard or suspected that something was not right. The Council’s whistle-blowing procedure, called Speak Out, was also available to staff. Safeguarding Adults training had been
Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 17 given to staff or was booked to take place. There were other procedures for the protection of residents and these included accepting gifts and bequests and what to do if a resident was missing from the home. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lived in a pleasant, safe, clean and well-maintained environment. EVIDENCE: The building was well maintained, clean and nicely decorated and furnished. A Handyman did all the minor repairs and decoration. Larger items of repair were done by Capita. There were four lounges, one of which was designated as a smokers lounge. This meant that residents had a choice of where they could spend their day. One resident said that the draft from the expel air vent in the window was making her cold – the senior staff rang Capita for this to be sorted out and were told that the fan would be removed and the window pane would be replaced. There was a large dining room. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 19 There were sufficient bathrooms and toilets all of which were large enough to assist disabled residents. There was a lift to the first floor. Aids for assisting residents included bath hoists, mobile hoists and a stand-aid. There was a call system to all areas. Residents had locks to their bedroom doors and lockable storage space for valuables. They were able to bring in their own possessions if they wished to. Some bedrooms had exposed hot water pipes that may pose a risk to some residents, especially if they are at risk of falls when in their bedroom. Residents spoken to were happy with the accommodation. The laundry had two domestic style washers. They did not have a sluice programme but did a hot wash, which reduced the risk of cross infection. Red alginate bags were seen for use with fouled laundry. There were two dryers. There was a sink with liquid soap and paper towels. There was a drying room where the clothes were sorted before being returned to residents. The laundry was done by the care staff. There were policies and procedures for infection control. Plastic gloves and aprons were available for staff to wear to prevent the spread of infection. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels were sufficient to meet residents’ needs. Thorough preemployment checks were made to ensure that staff were suitable to work with vulnerable people. Training was given to ensure that staff had the skills and knowledge to do their work in a competent manner. EVIDENCE: There was a duty rota that detailed the name of the staff and the hours that they worked. From the staffing rota and observation, there were sufficient care and ancillary staff on duty to meet the needs of the residents. The use of Agency staff had now been discontinued and this meant greater consistency in care for the residents. The officer in charge rota was not an accurate record of who was on duty at the time of the inspection. The file for a new member of staff was examined. This showed that the recruitment had been done in a thorough manner. There was an application form with a full employment history. References and a Criminal Records Bureau check had been obtained before the person started work. The member of staff was spoken to and she confirmed that her recruitment had been done properly. There was evidence that new employees were given a thorough induction so that they had the basic skills and knowledge to allow them to do their work.
Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 21 The amount of training given to other staff had improved. There was evidence that all had either completed, or were booked to attend, all of the mandatory training required. Staff said that training needs were discussed in supervision. Nearly all of the care staff had the National Vocational Qualification in care. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed. Residents were able to give their views on how the home was run and these were acted upon. Resident’s financial interests were safeguarded. The health, safety and welfare of staff was protected. EVIDENCE: There had been a new manager registered for the home. She had 28 years experience of care with seven of these in management. She had the National Vocational Qualification in care Level 4 and was doing the Registered Managers Award. She also did all the mandatory training. She had a job description and was aware of the lines of accountability in the organisation. The home had the Quality Assurance award from Blackburn with Darwen Borough Council. The manager had an action plan and was working through
Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 23 this. She said that she did some internal audits for example, finances, medications, and building maintenance, but these were not recorded. Surveys were done on a monthly basis by the activity co-ordinator. If any issues arose these would be brought to the attention of the manager and action taken. There was no overview of the results. Resident meetings and staff meetings were held. This meant that both groups of people could have the chance to make their views known to the Manager. Staff members spoken to confirmed that meetings were held and that they could voice their opinions. No member of staff was an appointee for any resident. There were records to show the payment of personal allowances, either as cash or into savings. Small amounts of cash were kept on the premises. Two of these were checked and found to be correct. There was a safe in the office and records kept of all valuables and money deposited with staff. The fire alarms were tested weekly. The extinguishers and alarm system were serviced. Portable Appliance Testing had been done. All other appliances had been serviced as required and there were certificates to demonstrate this. All staff had received, or were booked to attend, updates in safe working practices. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 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 X X X X X x 3 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement Staff must make intermittent checks to ensure that residents who self-administer their medications are doing this correctly. There must be a duty roster and a record of whether the roster was actually worked so that there is an accurate record of who has been in the home at any time. (Previous time frame of 11/03/06 not met) Timescale for action 07/12/07 2. OP27 17(2) Schedule 4 07/12/07 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. 2. Refer to Standard OP7 OP19 Good Practice Recommendations Staff should ensure that documents in the care plan are filed correctly so that the information they contain is readily available. Residents whose bedrooms have exposed hot water pipes should be risk assessed to ensure that these do not
DS0000034755.V355923.R01.S.doc Version 5.2 Page 26 Greenways 3. OP33 present a hazard to their health and well being. The manager should ensure that there are quality assurance systems to monitor the care and services provided at the home. Information from residents’ surveys should be collated and made available to interested parties. Greenways DS0000034755.V355923.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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
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