Inspection on 23/05/07 for Grove Court (Woodbridge)

This inspection was carried out on 23rd May 2007.

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

Grove Court (Woodbridge) 23/05/06

Grove Court (Woodbridge) 10/10/05

Grove Court (Woodbridge) 13/07/05

Grove Court (Woodbridge) 22/11/04

Grove Court (Woodbridge) 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Grove Court (Woodbridge) Beech Way Woodbridge Suffolk IP12 4BW Lead Inspector Jane Offord Key Unannounced Inspection 23rd May 2007 09:00 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 Grove Court (Woodbridge) DS0000024401.V341067.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. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove Court (Woodbridge) Address Beech Way Woodbridge Suffolk IP12 4BW 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) 01394 446500 01394 446501 raphy.perez@efhl.co.uk Elizabeth Finn Homes Ltd Mr Raphael Perez Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (61) of places Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Condition of Registration The Home has approval to care for one named service user (as per application for variation dated 19/8/05) under the age of 65 with palliative care needs. 23rd May 2006 Date of last inspection Brief Description of the Service: Grove Court is owned by Elizabeth Finn Homes and is registered as a care home with nursing, accommodating a maximum of 61 older people. The home is located on the outskirts of Woodbridge town centre. To fit the slope of the land, the home is built on three floors, lower, middle and upper. The main entrance is located on the middle floor at the front of the building, with appropriate signage and parking nearby. Internally the building is modern and attractive in design, with communal and private accommodation at all levels. All bedrooms are single accommodation with en suite toilets, with some having en suite shower facilities. There are two dining rooms, a number of lounges including an activities lounge, library, physiotherapy and sensory rooms, hairdressing salon and shop. Externally there are attractive well-maintained gardens with views down to the River Deben. There is a central courtyard and patio area that can be accessed from a number of doors and has seating so residents can enjoy the planted containers. The fees for accommodation range between £640.00 and £840.00 weekly and do not include toiletries, hairdressing, newspapers and chiropody. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection looking at the core standards for care of older people took place on a weekday between 9.00 and 17.00. The registered manager was present throughout the day and assisted with the inspection process. This report has been compiled from information available and evidence found during the inspection. During the day a tour of the home was undertaken but all areas were revisited again later. Part of a medication administration round was followed and care practice was observed. A number of residents’ files and care plans were seen and several residents and staff were spoken with. A selection of other documents was looked at including staff recruitment files, medication administration records (MAR sheets), duty rotas, menus and maintenance records. On the day residents were using all areas of the home and looked relaxed and comfortable. Interactions between staff and residents were friendly and appropriate. The home was clean and tidy with attractive décor and furnishings. Visitors were welcomed. The lunchtime meal looked appetising and residents spoken with said they had enjoyed it. What the service does well: What has improved since the last inspection? No requirements were left at the last inspection but the redecoration programme has continued with new carpets in some rooms and one of the lounges. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5, 6. Quality in this outcome area is excellent. People who use this service can expect to be given the information to make an informed choice about living in the home. The home does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s statement of purpose was seen and it was a well-produced document that contained all the required information about the service offered by Grove Court. It was up to date and had a copy of the last report, residents’ comments about the service and the complaints policy. It was available in large print if that was needed. Three new residents’ files were seen and each contained a contract with terms and conditions of their occupancy of the accommodation. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 9 Each file had a pre-admission assessment for the resident that covered areas of need such as diet, communication, mobility, oral and foot care, continence, cognition, social interests and family involvement. Other information included was a life history, past medical history and any religious beliefs. The manager and staff said prospective residents and their families were welcome to visit the home and see the service offered. One resident spoken with said they had visited a friend in the home before deciding to come in themselves so they had prior knowledge of the standard of service available. Another resident said they had been admitted from hospital but a member of their family had been round the home on their behalf. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. People who use this service can expect to be treated with respect and have their needs met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home uses a computerised care planning system based on the activities of daily living (ADLs). Each file seen had an up to date care plan with interventions for support in areas of care such as eating and drinking, personal hygiene, maintaining body temperature, (‘ensure XXXX is correctly dressed for the weather/monitor radiators and windows’), mobility and continence. Other headings were for work and play, sleeping, privacy and dignity and dying and final wishes. One resident needed extensive dental work and the intervention under privacy and dignity said, ‘respect YYYY’s wishes to remain in their room until the dental care is completed’. One resident registered blind had an intervention under communication to ensure their talking clock was to hand at all times. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 11 In discussion with a care worker about their role it was identified that they were aware that one resident had requested that same gender carers deliver personal care. This was confirmed later when the resident was spoken with. The resident also talked about some difficulty settling into the home and the implications that receiving care had for them personally. Neither of these two issues were reflected on their care plan. There was evidence that an assessment of need took place on each resident within thirty-six hours of admission and there was a review of the placement with the resident and their family after six weeks. A letter was sent to the resident summarising the discussion in the review meeting and any actions taken as a result of issues raised. The files contained risk assessments for moving and handling, nutritional needs, skin integrity and falls. One moving and handling assessment done by the physiotherapist said, ‘resident has progressed since admission and now walks independently for short distances’. Some files had risk assessments and consent for the use of bed rails, signed by the resident or a relative. Details of contact for the resident’s GP were in the file and also any hospital appointment that had been made. In discussion with the manager the procedure for monitoring any health changes of a resident was explained. The clinical care manager would be notified of deterioration or improvement in a resident that meant a re-assessment was required and the possibility of moving from residential care to nursing care or vice versa. The procedure is not formalised and the manager agreed to look at producing a protocol for guidance. Part of a medication administration round was followed and the nurse gave medicines to residents sensitively, helping them as required, offering tablets one at a time or all together as the resident chose. A non-touch technique was used to dispense tablets. It was noted that two prescriptions of liquid medicine for one resident were dispensed together into the same pot. MAR sheets seen were correctly completed with signatures or codes used. Each MAR sheet had an identification photograph of the resident with it. The home uses a monitored dosage system (MDS), so blister packs are filled by a local pharmacy and delivered to the home on a monthly basis. The medication policy and procedures issued by Elizabeth Finn Homes was looked at and contained guidance on ordering, storing, administering and disposing of medication. It covered the covert administration of medicines and altering them from the manufacturers’ licensed format. The section on procedures to be followed if CDs are lost or missing did not make it clear that the incident must be reported to the police. Two managers from Elizabeth Finn Homes were in the home on the day of inspection and said they would take action to correct that guidance. CSCI have since been supplied with a copy of the updated policy. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 12 The CD register and some stocks at random were checked on the day with the clinical care manager. The stocks tallied with the records. Grove Court (Woodbridge) DS0000024401.V341067.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, 15. Quality in this outcome area is excellent. People who use this service can expect to follow a lifestyle of their choice and be offered a wholesome diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the residents’ files seen contained contact details of their next of kin and daily records noted when residents had had family visitors or been out with them or friends. People spoken with said that visitors were welcome at any reasonable time and staff always greeted them politely. Visitors were able to have meals with residents if they wished and a separate section of one dining room was set aside for that purpose and to offer privacy. The home employs an activities co-ordinator and one lounge area upstairs is designated the activities room and contains a small pool table, a selection of books and videos and an electric organ. The home has a library room with a wide choice of books but also has visits from local people who will regularly source books specifically requested by residents. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 14 The activities co-ordinator produces a monthly activity programme that includes the times for Holy Communion, the hairdressers, any musical entertainment and outings for shopping or afternoon tea. The home has a bar in one of the lounges that is opened before lunch and some evenings so residents can socialise and take a pre-meal drink. A group of local people who take an interest in the home, called the House Committee, support outings and activities with time and finance so before Easter a complimentary drink was offered for residents by the Committee in the home’s bar. A newsletter is produced to let residents know of proposed events such as a visit from Bettercare Shoes or a talk about, ‘travelling up the Amazon’. Committee members are available to read books and letters to residents who have poor eyesight or just wish for the company. The activities co-ordinator said musical events are very popular with the residents and they generally try to organise at least one a week. They arrange videos to reflect religious holidays so for Easter they were showing, ‘Jesus of Nazareth’. Residents spoken with said they enjoyed the events that were organised but also that they had the choice of participating or not. The lunchtime meal was a choice between gammon or a lentil curry. The meal looked and smelt appetising and residents said they had enjoyed their choice. Menus seen showed supper offered a choice of fresh potato and watercress soup, goats cheese and red onion tart or a chicken and grape salad followed by rice cream or yoghurts and fruit. The home has appointed a new chef manager in the last few months who intends to consult regularly with the residents about the menus. The manager said a food questionnaire is to be distributed to all residents early next month. Grove Court (Woodbridge) DS0000024401.V341067.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, 18. Quality in this outcome area is good. People who use this service can expect to have complaints taken seriously and be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is available with the Statement of Purpose and a copy in the entrance hall of the home. Residents spoken with were clear about who they would approach if they had a complaint or concern about the service. CSCI is aware of two recent complaints and the manager was able to supply documentation to support the full investigation and response that had taken place following both incidents. The incidents were resolved to the satisfaction of the complainant each time. Protection of Vulnerable Adult (POVA) training is part of the home’s annual, mandatory training programme and is included in the induction programme for new staff. The home has a POVA policy to reflect local guidelines and a whistle blowing policy to protect staff who report concerns. Staff spoken with were clear about their duty of care and were able to identify imaginary situations that could demonstrate that subtle abuse was taking place such as neglect by omission of medication. Grove Court (Woodbridge) DS0000024401.V341067.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, 26. Quality in this outcome area is excellent. People who use this service can expect to live in comfortable and pleasant surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This purpose built home was opened in 1999. It offers individual rooms to sixty-one residents. The rooms all have some en suite facilities with those in the residential section having a shower as well as toilet and basin. The layout over three floors is airy and spacious. All the rooms look over the large gardens or the well-maintained central courtyard. The décor and furnishings are bright and fresh with furniture appropriate for the client group. Access between the three floors is by stairs or passenger lifts. On the day of inspection the tour of the home found it clean and tidy with no unpleasant odours. There were fresh flowers in many of the communal rooms. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 17 The gardens cover some fifteen acres and are maintained by two gardeners. Level access to the gardens and the courtyard is available from a number of doors at different levels in the home, which is built on a slope so has three stories at the rear and two at the front entrance. The décor and furnishings throughout the home were well maintained with several bedrooms and one lounge having been redecorated and had new carpet laid recently. It was noted that a number of double glazed window units had faulty seals allowing condensation to build up between the glass panels. The manager said there were plans to change them. The laundry was visited and contained washing machines with sluice programmes. It was clean and designed to have two doorways so there was an entry for dirty linen and an exit for clean linen. Staff were able to explain the precautions taken with soiled linen to prevent cross infection. Grove Court (Woodbridge) DS0000024401.V341067.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, 30. Quality in this outcome area is good. People who use this service can expect to be supported by adequate numbers of correctly recruited staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is divided into three ‘care bases’ one of which is for residential residents and the other two for people requiring nursing care. The duty rotas showed that during the morning shift there were two trained nurses with twelve carers, in the afternoon and evening there were two trained nurses and nine carers, overnight the numbers were two trained nurses and four carers. The management team included a Head of Clinical Care and a Head of Residential Care, a Housekeeper manager and Chef manager as well as the registered manager. Ancillary staff for the laundry, kitchen, gardens and administration supported the whole team. Staff spoken with on the day said there were enough people to meet the needs of residents. They felt the team worked well together. The staff work in one care base for a period of time and then the care staff move to another followed two weeks later by the trained staff so that there is some continuity for residents and the incoming team can be adequately introduced and have an indepth handover for the new area. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 19 Residents said staff were willing and responded quickly to their requests for support or care. It was noted that call bells were answered swiftly. The files for three new members of staff were inspected and each one contained documentary evidence that showed proof of identity, two references for care staff and three for trained nurses and a recent photograph of the person. For each file seen the administrator showed the criminal records bureau (CRB) check that had been done and for one trained nurse proof was given that their personal identification number (PIN) for practising had been renewed. Records of induction covered fire awareness, health and safety, food hygiene, moving and handling, infection control and POVA. This was confirmed in discussion with carers. A carer spoken with was able to discuss infection control precautions taken and the method for managing soiled linen to reduce the risk of cross- infection. They said they had ongoing training and were going to be doing a course about dying and bereavement. The home employs forty-eight care staff excluding trained nurses. Twenty-six of them hold an NVQ in care at level 2 or 3. This represents a percentage above the 50 recommended by Standard 28 of the National Minimum Standards (NMS). Six further staff are at present studying for an NVQ level 2. Grove Court (Woodbridge) DS0000024401.V341067.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 good. People who use this service can expect it to be run in their best interests and be protected by the policies in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: CSCI carried out a random inspection of this home in February 2007 following the unexpected death of a resident. The manager and Elizabeth Finn Homes supplied all the information required by CSCI and co-operated in having a management review meeting. No requirements or recommendations were made as a result of the random inspection but it was clear from discussions during this inspection that the understanding of the assessment process is deeper and underpins management practice. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 21 Resident/relatives meetings are held regularly and minutes are available. The most recent meeting had been a week ago and the minutes showed a wideranging discussion about a variety of subjects from food to saving electricity. The manager said the residents had made a request to rotate the seating arrangements in the dining rooms so that residents did not always sit with the same people. They had devised a system of changing the residents to new tables every six weeks and residents spoken with said they were happy with the plan. The administrator explained the system for managing residents’ personal monies. Records required two signatures and there was a clear audit trail. Money was kept in a safe in the administrator’s office and the keys were secure. Wallets that were checked at random tallied with the records. Care staff spoken with said they had regular supervision sessions with senior staff in which concerns and issues were openly discussed and training needs identified. Ancillary staff including the managers did not have supervision nor offer supervision to their team of staff. The registered manager confirmed that the supervision programme did not extend to the ancillary staff but agreed that it should. Records were seen for portable appliance testing (PAT) of electrical equipment such as televisions, music centres, lamps, toasters and kettles. They were all in date with review dates set. Records for the monthly test of hoists and the annual test of beds were seen. Some records showed the piece of equipment had failed the testing but there was no evidence of what had been done. Whether the piece of equipment had been removed from service for repair or been scrapped was not recorded. The fire log had evidence of weekly alarm tests and emergency lighting, monthly fire drills and an annual inspection carried out by Suffolk Fire Protection Services. There were records to show weekly checks on lifts and that unused showers were run on a weekly basis to prevent the possibility of Legionella. A visit to the kitchen found that it was tidy and food was correctly stored but some areas of décor and the floor covering would be difficult to clean to the standards required. Some of the design of the kitchen does not lend it to a logical ‘flow’ of activity and there is the possibility of health and safety risks with the lack of worktop on one side of the gas cooker and the height of some other pieces of equipment. Grove Court (Woodbridge) DS0000024401.V341067.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 4 4 4 X 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (1) Requirement Care plans must contain interventions that reflect the expressed wishes about how a resident wants to be supported to ensure their needs are met appropriately. Liquid medications must not be mixed in the same pot to ensure accurate monitoring of the amount of each medicine the resident takes. The programme of staff supervision must be extended to all staff to ensure that residents are supported by suitably informed and trained staff. A procedure must be put in place to allow an audit trail to follow up the action taken when equipment fails a service test to ensure faulty equipment is not used putting residents at risk. Timescale for action 23/05/07 2. OP9 13 (2) 23/05/07 3. OP36 18 (2) 31/08/07 4. OP38 23 (2) (c) 30/06/07 Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 24 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 OP38 OP38 Good Practice Recommendations A review of the layout and décor of the kitchen should be undertaken to allow for easy cleaning and a safe, practical working environment. The plans to replace faulty double glazing units should be progressed so that residents live in a pleasant environment. Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. Extracts may not be used or reproduced without the express permission of CSCI Grove Court (Woodbridge) DS0000024401.V341067.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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