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Inspection on 23/08/06 for Harry Lord House

Also see our care home review for Harry Lord House for more information

This inspection was carried out on 23rd August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home had taken action to review its statement of purpose and service user guide to reflect some of the changes since the last inspection. This information is available to residents and relatives. The site visit took place when a lot of development work was being done and there was restricted access to the ground floor. The manager and staff demonstrated that appropriate action had been taken to manage and support residents, relatives and visitors during this period of development of the site. The home continues to ensure residents are offered a choice at meal times and that residents were provided with small group activities and supported to maintain community links with families and church representatives.

What has improved since the last inspection?

The content of monthly internal monitoring reports provides informative information about the conduct of the home and evidences that systems are in place for internal monitoring of the service. There was evidence that information provided to residents and relatives had been reviewed to ensure information was current and reflected proposals for the development of services at Harry Lord House. There was evidence that action had been taken to address some short falls in the management and review of care and risk assessments identified through the internal monitoring arrangements. Staff confirmed that programmes of supervision and training were established and supported their development. The staffing levels were appropriate to meeting the needs of residents following the reduction in overall numbers of residents accommodated. Work had been completed on the installation of a new fire detection system.

What the care home could do better:

The home is again advised to do a summary report of the findings of recent questionnaires to residents on their view about the service they receive. The summary report should be incorporated into the homes statement of purpose to evidence that consultation with residents takes place.

CARE HOMES FOR OLDER PEOPLE Harry Lord House 120 Humphrey Road Old Trafford Manchester M16 9DF Lead Inspector Joe Kenny Unannounced Inspection 23rd August 2006 11:45 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 Harry Lord House DS0000032586.V309363.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. Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harry Lord House Address 120 Humphrey Road Old Trafford Manchester M16 9DF 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) 0161 872 4156 Trafford Metropolitan Borough Council Mrs Susan Burrell Care Home 45 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home provides accommodation for a maximum of 45 service users, 29 of whom require care by reason of old age (OP) and 16 of whom are older people who require care by reason of dementia (DE(E)). Separate lounge and dining space must be provided to meet the needs of the service users who require care by reason of dementia (DE(E)). There are currently 8 named older service users who require care primarily by reason of mental ill health (MD(E)) and 1 named older service user who requires care primarily by reason of physical disability (PD(E)). Should any of these service users no longer require accommodation at the home, 7 of the places will revert to the category (DE(E)) and 2 of the places will revert to the category (OP). The Statement of Purpose must be maintained in line with the requirements of Schedule 1, of Regulation 4(1) of the Care Homes Regulations. The Statement must be kept under review and updated. Any changes to the homes purpose must be agreed with the Commission for Social Care Inspection prior to implementation. The staffing arrangements at the home must be maintained in line with the minimum levels set out in the guidance published by the Residential Forum, `Care Staffing in Care Homes for Older People`. This must be reflected in the Statement of Purpose. The home must be managed at all times in accordance with the guidance and regulations issued in respect of older peoples` homes by the Secretary of State for Health under Sections 22 and 23(1) of the Care Standards Act 2000. The authority must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 25th January 2006 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Harry Lord House is a care home, owned and managed by Trafford Metropolitan Borough Council. The accommodation arrangement and conditions of registration had significantly changed since the last inspection and the certificate of registration in respect of the home will be will be amended to reflect these changes. Accommodation arrangements are now on 2 floors. The first floor is undergoing programme of change to develop a day service for older people and an Asian Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 5 and Afro Caribbean centre. Access to the first and second floors, where bedrooms and communal areas are located, is by staircase, or vertical passenger lift. There are four lounges and a wide variety of bathing facilities, including a walk-in shower and Parker bath. All bedrooms offer single occupancy. The number of bedrooms has now reduced to 28 beds. The home is situated in a quiet residential area and is close shops, public park and the Metro link at Trafford Bar. The fees for the home are £380:29 Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out on the 23 August 2006. As part of the inspection time was spent in discussions with staff, residents, and the manager on care and social arrangements relating to the residents. Time was spent examining records relating to residents, staff and those records required to be maintained relating to the management and administration of the home. Prior to the inspection, information was provided by the home in the form of a pre inspection questionnaire, comment cards sent to residents and relatives were also returned to the Commission. What the service does well: What has improved since the last inspection? The content of monthly internal monitoring reports provides informative information about the conduct of the home and evidences that systems are in place for internal monitoring of the service. There was evidence that information provided to residents and relatives had been reviewed to ensure information was current and reflected proposals for the development of services at Harry Lord House. Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 7 There was evidence that action had been taken to address some short falls in the management and review of care and risk assessments identified through the internal monitoring arrangements. Staff confirmed that programmes of supervision and training were established and supported their development. The staffing levels were appropriate to meeting the needs of residents following the reduction in overall numbers of residents accommodated. Work had been completed on the installation of a new fire detection system. 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. Harry Lord House DS0000032586.V309363.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 Harry Lord House DS0000032586.V309363.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident and relatives are provided with revised documents and information about the home to enable them to make informed decisions about how the home will meet their needs. Residents were admitted to the home following a full assessment of needs. EVIDENCE: The home’s Statement of Purpose and Service Users’ Guide had been revised and an up to dated copy was received on inspection. All documents were reviewed in May 2006 and again in August 2006. Each document clearly sets out current information about the home in order to reflect the changes which have occurred in the home over the last few months, the most notable being the reduction in over all bedroom numbers. All Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 10 bedrooms are now located on the first and second floor. The home provides care to a total of 28 residents, 14 requiring care by reason of old age (OP) and 14 who require care by reason of dementia (DE (E)). The information was clear and detailed, gave a description of the staff team and the care and services provided at the home to meet the assessed needs of residents. The Statement of Purpose and Service Users Guide informs relatives of the method to raise complaints and must include the contact details for the Commission for Social Care Inspection. The Statement of Purpose refers in one section to the N.C.S.C and should be amended to Commission for Social Care Inspection (C.S.C.I). The Service Users’ guide is available to all residents and is located in their room. The manager was advised to include information in the service user guide and in the terms and condition of placement about the fees for care, payable and by whom. At the time of the inspection there were 22 long stay residents, one resident in hospital, two residents on respite care and two vacant beds. The home does not provide intermediate care. Harry Lord House DS0000032586.V309363.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 at least once during a 12 month period. 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 health and personal care needs of residents were being met by the home through planning and delivery of care. EVIDENCE: Prior to an admission to the home, the manager confirmed that the home will receive a referral and care assessment form in respect of the resident being referred. This information is provided for all residents referred for long term or respite care. No long term placement have occurred since the last inspection of the home. This was in part due to the alterations occurring in the home. As part of the admission process residents are encouraged to take up a trial visit and this enables the home to complete its own personal profile of the resident referred, including personal information to assist in the development of care plans and strategies to manage any identified risks. The manager further stated that issues relating to mobility and physical ability of residents Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 12 would be looked at on admission to assist in determining which room would be most suited to their needs in light of the fact that some of the rooms are slightly under size. The care plans of residents set out the assessed needs, plans of support and health care intervention to support individuals. Each resident is assigned a named key worker. From information provided by the manager and from comments by residents, there was a clear emphasis on involving relatives in the delivery of care. However the home is advised to ensure this process includes all relevant relatives as one relative completing the comment cards indicated they were not consulted on care issues. The care plans for residents were randomly examined and were found to contain informative information about the levels of support and identified risk for each individual. Information recorded by staff in the daily notes demonstrated that consistent and clear records were being maintained to evidence the support and care offered. Residents’ files are held securely and the senior has responsibility to monitor the content of information to ensure specific care issues such as weight and bathing plans are completed. The care plan is divided in ten sections under a designated heading. The section on care plan reviews for the files examined confirmed that monthly reviews of care do taken place. No resident required care relating to pressure care at the time of the inspection. The arrangements for administration of medication were found to be held securely and on inspection the records and medication held for individual residents was in order. Six named staff were responsible for the administration of medication. A named residential officer has responsibility for procedures relating to the ordering, receipt and storage of medication. The residential officer and a senior check medication on receipt. Medication returned to the chemist is checked and a record kept. The relatives of residents admitted for respite care receive a letter informing them of the procedure for administration during their stay. This ensures safe practices are followed during their stay and all medication must be received as prescribed by their General Practitioner. The home is advised to ensure any hand written entries on the medication administration sheet are countersigned by a second member of staff. A medication care plan was in place for administration of prescribed cream held in residents’ own bedrooms. Medication procedures were assessed to be in order on this visit. Harry Lord House DS0000032586.V309363.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 at least once during a 12 month period. 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. The arrangement for daily living and social activities meet the assessed needs and preferences of residents. Social, cultural, religious and recreational activities arrangements are provided to residents to choose from. EVIDENCE: Residents and relatives, through comment cards and in discussion on the day stated that they had been supported by staff to deal with the many changes occurring in the home since the last inspection. Daily living arrangements were affected by programmes of rewiring, installing a new kitchen and location of all bedrooms to the first and second floor in order to leave the ground floor vacant for development of day resource services. Residents stated they could access their bedrooms when they wished and could arrange how they spent their day. Residents come together in small lounges located close to their bedrooms. Each lounge has a small kitchenette area for preparing beverages and light snacks. Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 14 There is a television and music centre in each lounge and a range of board games are available in each lounge and a member of staff is assigned to each lounge to support residents. Relatives and residents commented that crafts and structured activities are available and organised by students from Trafford College. However during the summer months, such structured events are not held on a regular basis as students are on leave. There is a need to sustain such programmes of activities to ensure the recreational and leisure interests of residents are being met. The home operates an open policy on visiting but asks relatives to avoid meal times when visiting. Residents have access to religious services on a monthly basis and communion services weekly. The home also holds regular meetings to which relatives are invited, to discuss issues relating to care and social interests. The meal and menu arrangements in the home demonstrated that residents are offered choice and are consulted on their preferences for all meal arrangements. Residents commented that meals were “good” and all meals are served in comfortable small units. A member of staff is present in each lounge to offer assistance if required. The plans of care continue to record specialisit dietary and nutritional needs of residents and how these will be met. Harry Lord House DS0000032586.V309363.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 inspected at least once during a 12 month period. 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. Procedures in the home ensure clear procedures are in place to deal with concerns about the service and issues relating to the protection of residents are acted upon. Staff demonstrated they were aware of procedures relating to protection of adults from abuse. EVIDENCE: The home had clear guidelines on dealing with complaints or concerns about the service it provided. No complaints were received by the home in the period since the last inspection. The manager is advised to ensure the contact details of the Commission for Social Care Inspection are provided to residents and relatives in the home’s Statement of Purpose and Service User guide. One relative did comment that they were not aware of the homes complaints procedure. The home is advised to periodically discuss this process with families and possibly through the focus group meetings. Staff demonstrated in discussions that they were aware of procedures relating to abuse and what they would do if a resident disclosed to them that they were being abused. Programmes of training have been provided to staff and all staff Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 16 had signed to indicate they had read the Local Authority procedures on dealing with abuse. Information available at the time of the inspection indicated that procedures are in place to protect residents form abuse. Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy providing residents with a comfortable environment, which was well maintained. EVIDENCE: Extensive programmes of development on the site were being conducted at the time of the visit. The programme of rewiring of a new fire detection system had been completed and all wood framed windows were replaced with PVC double glazed frames. People entering the home are informed of health and safety arrangements to be observed as extensive work continues on the development of day service on the ground floor. Health and safety arrangements are closely monitored by the Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 18 manager of the home who liaises with the health and safety officer for the contractors carrying out the work. The number of bedrooms in the home had reduced to 28 and communal areas are offered in four separate group settings close to bedrooms. Programmes of decorating are to start as some damage is still evident where rewiring has been done. The building in general was found to be clean and each of the small units were found to be well maintained and suitably furnished. There was evidence the staff had access to disposable aprons and gloves in bathrooms and paper towel dispensers were also provided to ensure effective infection control procedures were followed. The main kitchen had been fitted out with all new stainless steel work surfaces and upgrading of the facility. Some areas were not yet completed where shelves had been removed from storage areas. The manager had set out procedures to be followed by all staff / personnel accessing the kitchen in light of the work being carried out on the ground floor. On touring the building there was a slight malodour which appeared to be managed by domestic arrangements and would be addressed through future redecorating programmes. Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 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. Residents benefited from a staff team who were trained, supervised and supported through formal training and supervision arrangements. EVIDENCE: The staffing arrangements and deployment of staff at the home were appropriate to meeting the needs of residents. There is a minimum of four staff and a senior on duty throughout the day with additional support of a residential officer. There are two waking staff and one person sleeping in on call through out the night. Additionally a manager is on duty during the day. The rotas confirmed these levels were being maintained. Each member of staff is assigned as key worker to named residents and on starting their shift are assigned to one of the four small units to support residents on that unit. Recruitment procedures, described by the manager ensured she was directly involved in the process of selecting and checking the suitability of staff. Programmes of training and supervision were established and staff had the necessary support in place for their development. Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 20 Staff confirmed they received regular supervision and training sessions. Information on training provided to staff, indicated that 10 care staff had completed NVQ II award and that 6 were currently undertaking the award. This represented an 84 ratio of the total care staff team. The senior management team and Residential Officers held the appropriate award relevant to their role. The manager is also completing the Registered Managers Award. The staff files contained required information to confirm recruitment procedures had been complied with and held information to confirm supervision and training programmes were available to staff. A record is kept of CRB checks conducted on staff and details the date completed and identification number. All staff had attended training on Understanding Dementia and further evidence of training on abuse awareness and Moving and Handling training had been provided to staff. The home continues to use agency staff to cover periods of sickness and staff vacancies. Regulation 26 reports on the conduct of the home are forwarded to the Commission on a monthly basis. The content of the reports are informative and demonstrate consultation with residents and staff on the conduct of the home. Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration procedures were developed in the best interest of residents. procedures were in place to promote health, safety and welfare of residents and staff. EVIDENCE: In the period since the last inspection the manager stated that she had reviewed all management and administration procedures to clearly set out the responsibilities of staff in line with their job description. This was evident in the information provided at the time of the inspection in the form of work action plans. The manager indicated that the review was as a result of some short Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 22 falls in day to day management of the home whilst she was on a period of leave. The manager continues to work toward achieving the registered managers award and demonstrated a commitment to supporting all staff on training issues. The home had completed a process of consultation with residents through use of questionnaires and was advised to complete a summary report of the findings of the survey to be included in the review of the statement of purpose. There was a clear commitment to health and safety issues in the home which was evidenced by procedures put in place to inform staff and visitors of heath and safety arrangements during this period of development and work being carried out on the ground floor. All fire safety tests and checks are carried out at the required intervals by a designated residential officer. The last recorded fire drill was held on the 19/08/06. Appropriate procedures were in place to support resident in the management of their finances. Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 3 3 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 3 X 3 Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 24 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 OP12 Regulation 16 Requirement Programmes of activity in the home must be sustained in consultation with residents, throughout the year Timescale for action 18/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 Refer to Standard OP1 OP9 OP16 OP33 Good Practice Recommendations The homes statement of purpose and service user guide should be amended to refer to the Commission for Social Care Inspection and not the NCSC. All hand written entries on the medication administration sheets should be counter signed by a second member of the staff team. The home is advised to ensure all relatives are made aware of the homes complaints procedure. The home is advised to complete a summary report of the findings of the survey carried out, involving residents and to included the outcomes in the homes statement of purpose. Harry Lord House DS0000032586.V309363.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Harry Lord House DS0000032586.V309363.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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