Inspection on 22/06/06 for Heathside

This inspection was carried out on 22nd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Heathside 30/07/08

Heathside 26/07/07

Heathside 28/12/05

Heathside 30/06/05

Heathside 03/11/04

Heathside 28/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Heathside Heathside Coley Avenue Woking Surrey GU22 7BT Lead Inspector Megan McHugh Key Unannounced Inspection 22nd June 2006 09:30 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 Heathside DS0000013671.V297906.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. Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathside Address Heathside Coley Avenue Woking Surrey GU22 7BT 01483 765046 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) sharon.blackwell@anchor.org Anchor Trust Ms Michelle Saville Care Home 51 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Old age, not falling within any other category (21), Physical disability over 65 years of age (8) Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE 28th December 2005 Date of last inspection Brief Description of the Service: Anchor Trust Ltd who also runs other establishments in the country runs this home. Heathside accommodates up to 51 residents including up to 20 service users with Dementia. The home has seven units over two floors and each unit has a dining room and lounge. All bedrooms are for single occupancy. There is a large lounge/day room on the ground floor that is usually used for activities. There is also a small seating area on the first floor as an alternative place to sit. The home was purpose-built and is located in a residential street close to the centre of Woking town. There are ample grounds and the house is well maintained. The environment is safe and homely and residents can benefit from a range of activities. The fee range is: £438.73 to £580.00. Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by Meg McHugh, Regulation Inspector for the service. The inspection was undertaken over a period of six and a half hours and was the first inspection in the Commission for Social Care Inspection (CSCI) year 2006 to 2007. The registered manager was present during the inspection process. One relative, six service users and two members of staff had in depth discussions and four service users and four members of staff had short conversations (in passing) with the inspector. Records were sampled and a tour of the premises was undertaken during the inspection process. The Commission would like to thank the staff and service users for their hospitality and cooperation throughout the inspection process. What the service does well: What has improved since the last inspection? The home has provided Dementia training for all staff from induction. A member of staff commented that the training had helped them understand service users who suffered with dementia and were able to communicate more effectively with them now. The staff member stated that they were able to provide better care and were more understanding because of the training. This was pleasing to hear. The medication policy has been amended to include a clear procedure to guide staff how to deal with drug errors. The senior staff member in charge of medication has drawn up a good policy that outlines the dangers to the service user should a medication be wrongly administered and includes not administering a medication. Heathside DS0000013671.V297906.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. Heathside DS0000013671.V297906.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 Heathside DS0000013671.V297906.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed prior to admission in to the home to ensure that the home is able to meet their needs. The home does not provide intermediate care. EVIDENCE: The Four files that were case tracked contained pre-admission assessments by the local county council and a short additional assessment from the home. The manager stated that they do not complete a detailed assessment as the county councils assessment is very detailed. A copy of the homes full assessment was seen and was satisfactory. One file sampled was for a respite client and this also contained the required information. Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 9 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 adequate. This judgement has been made using available evidence including a visit to this service. The care planning process and records were satisfactory but need to be kept under monthly review to ensure service users needs are being met. Risk assessments processes must be strengthened to keep service users safe and for staff to be aware of these risks. Medication administration records were satisfactory and training was comprehensive. Medication administration records must be kept securely. Service users rights and privacy was respected. EVIDENCE: Four care plans were sampled in depth and a number of other care plans were viewed during the inspection process. The home uses an Individual Lifestyle agreement or ILA system for their care plans and this was seen to be holistic in nature and included physical, mental, emotional, social and personal care needs. This was very positive to see. Many service users had a short quick glance style plan in the front of their file as well so that staff could see the basic care needs quickly. Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 10 Not all the units care plans sampled were reviewed on a monthly basis although the paperwork for the review clearly states monthly review. The home has a risk assessment plan in place and staff talked about completing their training in risk assessment. However it was noted that two of the four files sampled did not have a falls risk assessment or a mobility assessment in place. One service users pre-admission assessment clearly stated that they were prone to falls and during the first few days of their stay in the home had a fall resulting in a hospital admission for observation and the service user injured because of this fall. However no falls risk assessment or mobility assessment was completed. The manager stated that this was unacceptable practice and informed staff to check the Lifestyle Agreements for all service users and ensure all have this in place and that the information is up to date. It was pleasing to note that many Lifestyle Agreements were signed by the service user and during the course of the day service users informed the inspector of their care plans and that they helped develop these when they were admitted. This indicated good consultation with service users. Service users health care needs are well met. All service users were registered with a GP surgery and some informed the inspector that they still attend their ‘old’ GP surgery that they attended prior to moving into Heathside. This was pleasing to hear. The home is supported by the district nurses and there was evidence in service users files of visits to or from the optician, dentist, audiologist, dietician and physiotherapist. A medication administration round was not observed during the course of the inspection, however policies and procedures were seen and these were in line with legislation. The home has developed a clear policy about actions to take in the event of medication administration errors and this included the effect any error could have on the service user. The staff member in-charge of this area was not on duty however records of the staff training and assessment were seen. Other records seen included disciplinary actions taken in relation to medication and retraining provided where required. The home has recently bought medication trolleys for each unit and medication was stored appropriately. All trolleys were secure and could not be removed from the unit. An immediate requirement was made that the Medication Administration Record (MAR) sheets must be locked away and not left on top of the medication trolleys as these contain private information about service users. This was actioned during the inspection. Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 11 It was recommended that any handwritten entries on the medication administration sheets included the prescriber’s name. The care practice observed during the inspection process showed that service users privacy is respected. The staff were overheard talking respectfully with service users and many service users stated that the staff are kind and respect their wishes. Staff were observed knocking on doors and it was noted in the Lifestyle Agreements what name the service user prefers to be called. Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 12 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. Activities provided were satisfactory and offered a good range of activities to suit as many service users as possible. Visitors are welcome in the home at anytime and the meals provided met service users needs. Service users exercise choice and control over their lives. EVIDENCE: The activities lady was on a day off on the day of the inspection, however the staff provided some activities in the garden in the afternoon. A copy of the programme of activities was provided and these showed a varied range of activities were provided to suit a wide range of service users likes and needs. The home has a large day room on the ground floor where many of the activities take place. Staff stated they try to provide some activities on their units for service users but many do not wish to participate. Service users spoken with stated that activities are provided and that many are very good. A service user stated that they sometimes take part but not always out of choice. The manager stated that the activities lady keeps records of who attends what activities and that she visits those service users who do not take part in the Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 13 planned activities in their bedrooms on a regular basis. In most of the units in the afternoon of the inspection, the service users were watching Ladies Day at Ascot and one service user was seen wearing a hat. This service user stated that it was ladies day and she must wear a hat. Many service users talked to the inspector about their visitors and stated that they can visit at any time. Some visitors were seen in the home although only one was spoken with. Service users talked about going into Woking town for shopping or for a walk with staff down the residential street. It was noted in the Individual Lifestyle Agreement (ILA) that service users religious requirements were recorded. Service users discussed choice and how they have control over their lives even though they require assistance with some activities. A staff member stated that ‘the service users are in charge here’ and he is just here to help them when they need help and not to tell them what to do. This was positive to hear. Another staff member discussed the training they had had in understanding dementia and he stated that since doing the training he can now understand service users who have dementia better and is now able to give the service users with dementia choice and control over their lives too as he is now aware of how to do this. This too was positive to hear. A copy of the menus provided was given to the inspector. These are varied and offer choice of meals. Comments from service users in relation to meals were positive. One service user stated that the meals were of a good standard and that they give you what you want to eat. One service user stated a preference for brown bread and stated that they are given brown bread instead of white. Another service user stated that they are a vegetarian and that the chef caters well for her dietary needs. The kitchen was not inspected during this key inspection. Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 14 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. Service users are confident that their concerns are listened to, taken seriously and acted upon. The service users are safeguarded against abuse. EVIDENCE: The homes complaints log was sampled and contained information about complaints made directly to the home and action that was taken by the home. The manager talked about the homes complaints procedure and evidence showed that this was followed. A service user stated that they knew who they would complain to should they need to do so and they stated that the homes service user guide was in their bedroom and this contained information they need about complaints. The complaints procedure was also seen above the visitors signing in book. Records sampled indicated that staff have had training in safeguarding vulnerable adults in their rights and responsibilities training in their induction. Other staff training records indicated that some staff have had further training in this area, including the manager. Staff stated that they were aware that they must report any incidents they are concerned about and discussed the types of abuse that can occur. The home has a service procedure and a copy of Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 15 the local multi-agencys procedures for protecting vulnerable adults. During a recent incident the home followed the correct steps for reporting an incident. Heathside DS0000013671.V297906.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was generally well maintained and kept in a good condition. However there were areas that were in need of attention. The home was clean and hygienic. One area was affected by the smell of smoke from the smoking area. EVIDENCE: During a tour of the premises it was noted that many areas of the home were due for redecoration and a number of carpets were in need of replacing. On the day of the inspection Anchors surveyor, who decides what work needs to be done, was in the home. The manager stated and records showed evidence that some carpets were due to be replaced last year but this was not done. The manager and the surveyor informed the inspector that those carpets and others would be replaced in the course of this year. A copy of the budget and the survey was provided to evidence the planned work and the work that was Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 17 not carried out last year. These areas will be looked at again at the next inspection to ensure that the work is being done as stated. The home comprises of seven (7) units over two floors, each unit with its own lounge and dining room area. There is a large day room on the ground floor for activities and a small seating area on the first floor. The garden is secure and accessible from the ground floor. There was a large marquee up in the garden to provide additional shaded areas although many of the seating areas in the garden were shaded. The home was clean and good infection control care practice was observed. COSHH (Control Of Substances Hazardous to Health) cupboards were locked on each unit and no items in this category were seen to be unattended in the home. The inspector observed that cigarette smoke could be smelt down the bottom of the unit F and only one service user was smoking at the time. The smoke was coming from the upstairs designated smoking area. This does not appear to affect any other areas of the home. This was discussed with the manager during the inspection. Some service users spoken to on Unit F stated that they could not smell any smoke. The manager stated that the majority of service users on unit F are smokers. It was required that the homes smoking policy and designated smoking area be reviewed to promote the health, welfare and rights of all service users and staff. Heathside DS0000013671.V297906.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 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. The home is staffed in order to meet service users needs. Staff training is satisfactory and the home is working towards meeting their targets of 50 staff with an NVQ qualification. Recruitment procedures were sound and protected service users. EVIDENCE: The staffing levels were satisfactory on the day of the inspection. The manager stated that there are eight care staff on duty with a senior care officer during the waking day (7:30- 20.00). This means that each unit is staffed with one carer and there is one carer to ‘float’ between the units. The manager stated that they are nearly fully recruited and when this is done they plan to have nine care staff and a senior on duty. This means that there will be a ‘floating’ member of staff for downstairs and one for upstairs. No service users were observed to be in any danger or in need of staff assistance when the unit was unmanned for few minutes and staff were heard talking to the staff in the next door unit to keep an eye on their unit when they had to leave for short periods. Service users stated that they were well looked after, get all the attention they need, staff are kind, we are treated very well and staff do not shout at us or get cross. These indicated that the home is not understaffed and that service users are treated well. Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 19 The home has a rolling National Vocational Qualification (NVQ) programme in place and staff discussed a workshop that was booked in the near future for those staff who wanted to start their training. The manager stated that some staff are NVQ assessors and that this speeds up the process and allows more staff to start their courses. Staff discussed what training they had received and this included mandatory training in fire safety, moving & handling, health & safety, 1st Aid, food hygiene and protection from abuse. Other training provided included medication training, principles of care, food presentation and dementia care training. The dementia care training was provided by Anchor and additionally by the Alzheimers society. Staff had to complete a workbook based on their training and wait for this to be marked before they were given a certificate of training. A staff member stated that since having the training about caring for people with dementia, he was now able to understand and provide a better level of care for service users with dementia. He stated that he had benefited greatly from this training. Four staff files were case tracked and these all contained the required information of proof of identity, Criminal Records Bureau (CRB) checks and two references. The recruitment procedure was discussed briefly with the manager. Heathside DS0000013671.V297906.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team was sound and the views of service users were actively sought. There were no concerns about service users financial transactions in the home. One issue was raised about the health, welfare and safety of service users in the home in relation to fire. EVIDENCE: The registered manager has been in post for many years and has her Registered Managers Award. The manager stated that the home welcomes feedback from all visitors and the service users. There are consistent efforts from both the management team and care staff to encourage service users to take part in the running of the Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 21 home. The monthly service user and relatives meeting was held on the 15th June 2006 and posters were seen in all units advertising this. The minutes of the meeting held in May were also found on the notice board in one unit. The service users and their relatives are regularly consulted when changes are planned. For example the home is planning to make the three ground floor units specialised to provide care for service users with dementia and the four upstairs units for older people. The manager stated that she has been having discussions with service users and relatives about this as some service users will need to move units. Although the manager stated that service user’s wishes and choice would be taken into account before any moves were made. The manager stated that there are opportunities offered for one to one discussions with her for service users, relatives and staff. Staff met regularly to discuss their involvement in the home and there is much teamwork observed. Staff appeared encouraged to suggest changes if they thought of any ideas that would benefit the residents. The manager stated and showed the inspector copies of the survey sent to service users in May 2006. The information is still to be collated and then will be made available. The manager stated that a relatives survey would be sent out later in the year. The bursar was able to discuss the homes financial records and informed the inspector how the individual service users records are maintained. The homes policy and procedures were adhered to strictly in dealing with any finances. The manager audits the finances once a week and the regional manager will audit these on some visits in order to ensure that service users finances are secure. No areas of concern were raised with the record keeping. There are a number of good health and safety policies and procedures in the home. The staff received training in all aspects of health and safety with regular yearly updates. There is a maintenance man available to take care of any day-to-day repairs and general checks on premises & equipment and contractors are also used. On the day of the inspection a regular fire alarm check was carried out. On one unit a jersey had been place over the top of the door (fire door) leading into the dining/lounge area, so when the alarm was activated, this door was unable to close properly. The jersey was removed by the inspector and later that day the jersey was found to have been placed back over the top of the door. The manager was informed and the jersey was removed immediately and the staff Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 22 member was spoken to about this practice. An immediate requirement was made for the health, safety and welfare of service users. Heathside DS0000013671.V297906.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 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 2 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 X X 2 Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 24 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. 2. Standard OP7 OP7 Regulation 15(2)(b) 13(4) Requirement Care plans must be reviewed on a monthly basis. All service users must have risk assessments for falls and mobility completed at the time of admission. Action plans must be put in place for service users found to be at risk. All medication records must be kept locked away and not left on top of the medication trolley. An immediate requirement was made. The registered manager must reassess the smoking area in the home and the effect it has on service users and staff, especially those on unit F. The registered manager should document discussions with those concerned. The registered manager must ensure that all staff are aware of the home’s fire prevention procedures and ensure that nothing is placed on or in front of a fire door to prevent it from closing properly. An immediate requirement was made. DS0000013671.V297906.R01.S.doc Timescale for action 06/07/06 29/06/06 3. OP9 17(1)(b) 22/06/06 4. OP26 12(3) 06/07/06 5. OP38 13(4) & 23(4) 22/06/06 Heathside Version 5.2 Page 25 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 OP9 OP19 Good Practice Recommendations It is recommended that any handwritten additions to the medication administration record include the prescriber’s name or designation. The registered manager should inform CSCI when the carpets have been replaced and other planned work (as per the survey) for the year is completed. Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Heathside DS0000013671.V297906.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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