Inspection on 23/07/08 for High Oaks (1)

This inspection was carried out on 23rd July 2008.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

High Oaks (1) 30/07/07

High Oaks (1) 26/04/06

High Oaks (1) 13/01/06

High Oaks (1) 09/08/05

High Oaks (1) 09/02/05

High Oaks (1) 14/10/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 High Oaks (1) 1 High Oaks St. Albans Hertfordshire AL3 6DJ Lead Inspector Jeffrey Orange Unannounced Inspection 23rd and 25th July 2008 08:15 High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 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 High Oaks (1) DS0000019422.V368826.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 Adults 18-65. 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. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service High Oaks (1) Address 1 High Oaks St. Albans Hertfordshire AL3 6DJ 01727 844 523 01727 844 523 highoaks@walsingham.com www.walsingham.com Walsingham 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) Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 6 30th July 2007 Date of last inspection Brief Description of the Service: 1 High Oaks is registered to provide care and accommodation for up to six young adults with a learning disability. It is maintained and operated by Walsingham and is situated in a residential area of St.Albans, Hertfordshire. The accommodation comprises a lounge/dining area, kitchen, bathroom, utility room, toilet and one bedroom on the ground floor. The ground floor bedroom would be suitable for a resident with a physical disability in association with a learning disability. On the first floor are five bedrooms, a bathroom and the office/staff sleeping accommodation. The home has ample parking area to the front with a large garden to the rear, which has seating areas accessible to residents. If they choose to, residents can help maintain the garden and grow a variety of fruit and vegetables for use in the home. Information about the service provided at High oaks, the Statement of Purpose and the Service User Guide, plus a copy of the latest inspection report, can be obtained on request from the manager or Walsingham. The fees for the service are based on individual assessments are currently in the range of £871 - £1149 per week (correct on 23/07/08). High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. This report is based on a range of information gathered to enable us to assess the care outcomes for people living in High oaks. The process included two visits to High Oaks in which it was possible to meet people who live in the home and to observe some of their routines. We also spoke to members of the staff team and to the home’s manager and looked at some key records including care plans and medication administration. We received completed surveys on behalf of people who live in the home giving their views on the care they receive and the home also submitted an annual quality assurance assessment (AQAA). The AQAA is a self-assessment document that focuses on how well care outcomes are being achieved for people living in High Oaks and also includes some useful statistical information about the home. We have also reviewed any information received by the Commission for Social Care Inspection (CSCI) since the last key inspection in August 2007. What the service does well: “When I want something or want to do something the staff help me but try to get me to do things myself” was one comment recorded on behalf of a person living in High Oaks. As many of the people living in High oaks use limited verbal communication or entirely non-verbal communication, the surveys whilst in pictorial format were completed with them. Comments recorded were overwhelmingly positive. The home is well maintained and provides a domestic style and character that promotes a homely environment for people living there rather than an institutional one. Although there were some challenging incidents observed during our two visits to the home, at all times the staff team maintained appropriate and supportive interaction with the people living in the home and all surveys received on behalf of people living in High Oaks were especially positive about the way that staff care for them. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 234 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Before anyone moves permanently into High Oaks they are involved in a thorough process of assessment to make sure that their individual needs are identified and that they can be met. They will be able to visit the home to meet the people already living there, which should help them decide if High oaks is a place they would be happy and could fit in. EVIDENCE: We found that there have not been any recent admission to the home, the latest being in 1999. This means that the people currently living at the home have been together for a number of years and have become accustomed to one another. The Home’s AQAA identifies that there are pre-admission forms that would have to be completed prior to any admission, along with a support plan. People considering moving into the home would be encouraged to visit the home and they would “dictate the speed at which they move into the service”. As the needs of individuals have changed, we saw evidence in the care plan documentation, confirmed by speaking to staff who told us that appropriate High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 9 reviews have been carried out and that action identified as necessary in the review process have been taken to make sure those needs can be met. The AQAA identifies the need to review the assessment documentation to make sure it is accessible to people who may be considering moving into High Oaks. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care is provided for people living in this service in a way that recognises their individuality and takes account of their personal preferences and goals, however this is not always fully reflected in care plan documentation. People living in this service are supported to take appropriate risks within a robust risk assessment framework, this recognises that taking reasonable risks, having identified and assessed them, is part of developing an independent lifestyle. EVIDENCE: When we talked to members of the staff team we found that they involved people who live in High Oaks in the process of planning care and support of their care and understood the importance of people living in High Oaks being able to take control of their own lives and as part of that process to take reasonable risks. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 11 People who live in High Oaks told us in the surveys that they returned that they always (3) or sometimes (3) make decisions about what they do each day. Everyone who lives in High Oaks answered yes to the questions in the survey ‘Can you do what you want to do during the day and in the evening.’ When we looked at care plan documentation and talked to the manager and staff about care plans we found that they have not yet been fully revised in order to reflect the person centred way the home operates. The home’s AQAA notes that “Health action plans are being put into place and the person centred plan is being further developed to ensure a more holistic approach to service user support” We were shown examples of the new care needs assessment that is being introduced, which is in a format that people living in the home will find easy to understand and which covers 14 areas of their lives and activity in the home. We saw that there are risk assessments in place for example dealing with how people can be helped to access the community safely and without unacceptable risk to themselves or others. “The staff try to get me out in the community as often as they can” one person noted. On both occasions that we visited the home there were incidents with members of the staff team being ‘slapped’ by a person who lives in the home. The staff concerned were observed to deal with this appropriately and in line with guidelines seen. A risk assessment was in place and had been updated and a meeting with health and social care professionals had been arranged to consider the implications and possible causes of this behaviour. Staff members completed the appropriate incident report form in both cases. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in High Oaks can be confident that they will be helped and encouraged to develop or maintain their social and independent living skills and that their rights as individuals will be respected. People living in High Oaks can be confident that they will be involved in meaningful and varied daytime and evening activities of their own choice and that they will be able to maintain family contacts in line with their wishes. EVIDENCE: Whilst we were visiting the home we were able to see people going off to a variety of destinations, some to the town with support, others going to day activities. When we talked with some of the people living in High Oaks they told us what they were going to do at day centres and one person told us they were going to their club that evening. “Sometimes I go out with staff for lunch or a drink in the pub or shopping” High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 13 Surveys received on behalf of people living in High oaks include comments such as; “The staff try to get me out in the community as often as they can” and “The staff are able to suggest things for me to do, sometimes I want to do it, sometimes I don’t” We were able to see records of meetings of people who live in High Oaks and these included some discussion of food and what was liked and not liked as much. There were no negative comments received about food in general and when we were in the home people living there seemed to be enjoying their breakfasts and were putting their packed lunches together. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in High Oaks can be confident that they will receive care in a way that respects their dignity and rights. People living in High Oaks can be confident that they will have access to the health care services they need, either in the community or the home and that their healthcare needs will be monitored and appropriate action taken. Although the home has a comprehensive medication policy it is not always fully complied with and this means that people who depend upon staff to help them with their medication could be potentially put at risk. EVIDENCE: We found that although there were minor shortfalls found with the home’s medication practice at the inspection of the home carried out in August 2007, there were still issues arising from this inspection that suggest that effective steps had not been taken to monitor routine administration of medication, which could put people living in the home at risk. We found that some medication was being recorded as given, even though stocks had run out some time previously. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 15 Some gaps were found in medication records that indicated that medication had not been given as directed. For example a course of penicillin included two days where it had not been given in line with instructions. “Staff forgot to give it” was the reason given. (The course was extended by two days to compensate) When we looked at medication we found that at least one had not been dated on opening, which means that instructions about when it should be disposed of after opening would be difficult to follow. When we looked at care plans we found that people living in High oaks were able to access the healthcare services they needed and that their health was monitored in a way that protects their wellbeing. All of the people living in High Oaks indicated in their responses to our survey that care staff “always” listen and act on what they say. “When I want something or want to do something, the staff help me but try to get me to do things myself” High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in High Oaks can be confident that their views will be actively sought and acted upon. They can be assured that the training staff have in recognising actual or potential abuse and the policies and procedures that are in place to help staff take appropriate action if it is seen or suspected provide people living in High Oaks with protection from abuse, neglect and self-harm. Although there is a comprehensive complaints procedure that is provided in a format that should ensure that service users could make any concerns or complaints known, some people living in High Oaks may need reminding about this regularly. EVIDENCE: Previous issues affecting the home have been dealt with and the rights of people living in the home have been fully protected. Walsingham co-operated fully with a previous safeguarding issue dealt with under the Hertfordshire County Council safeguarding procedure and enhanced training was provided for staff to help them protect people living in the home from potential or actual abuse. When we asked people living in High Oaks they told us in their responses to our survey that care staff “always” listen and act on what they say. When we asked people living in High oaks if they knew how to make a complaint, only half responded ‘yes’. This suggests that they may need to be High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 17 reminded regularly so that they are clear about how they can ‘complain’ if they want to. The AQAA tells us that the home have recognised the need to make complaints documentation more accessible for people living in High oaks. Some of the surveys returned on behalf of people living in High Oaks contained phrases and comments that seem unlikely to have been obtained directly from them, for example “As I can be lazy at times I need encouragement to motivate myself”. When we discussed this with the manager we were told that in future it might be possible to involve advocates in the completion of such surveys to ensure the views expressed are consistent with those of the people on whose behalf they are being completed. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in High Oaks benefit from an environment that is safe, comfortable and homely and that is kept clean and tidy. EVIDENCE: When we went around the home we found that it was generally very clean and tidy. We saw people living in the home using the lounge and dining areas and they appeared to be very comfortable and well furnished in a way that was domestic not ‘institutional’. We did see two areas of flooring in bathroom/toilets that were badly stained around the base of the pedestal. This was discussed with the manager who told us that this was recognised as needing to be rectified. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 35 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Because of the lack of sufficient permanent staff, people living in High Oaks receive most of their care from agency staff and this could adversely affect their long- term wellbeing. People living in High Oaks can be confident that where people are recruited as permanent staff, they are subject to a rigorous process, which should prevent the employment of unsuitable people to care for them. People living in High Oaks can be confident that permanent staff are provided with training to support them to care for people living in the home appropriately, however levels of NVQ training are still unsatisfactory. EVIDENCE: The home’s AQAA tells us that none of the home’s permanent care staff have NVQ level 2 or are working towards it. This was also recorded as the case in the previous inspection report of August 2007. The AQAA confirms that all permanent staff have an up to date training plan and notes that Walsingham are linked to a national training organisation to validate their training. This provides people living in the home with permanent staff whose training is both structured and independently assessed for quality. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 20 Although Walsingham attempt wherever possible to use agency staff who are familiar with the home and the people living there, this cannot always be achieved and can adversely affect at least one person living in the home, who finds changes in staff particularly difficult to deal with. This is the third report that has raised concerns about staffing arrangements in High Oaks. We were told that it is still the case, as recorded in the last report, that agency staff cannot attend staff meetings or have formal supervision. In a service that has relied to a very large extent for the past year on a high proportion of care hours being filled by agency staff, this does not provide a fully integrated staff team and appears counter productive. On the first day of the inspection the home was being managed by a part-time permanent member of the care team up to 11 am and by agency staff in the afternoon. This was due to both the manager and deputy manager being on annual leave. The person in charge was not aware of the alternative contact for senior management support on the day, as the senior manager usually responsible for the home was also on annual leave. It is recognised that Walsingham are endeavouring to recruit more permanent staff and we were told that there is some hope that the position may soon improve. This will benefit everyone who lives and works in High Oaks. Although no staff have recently been recruited, it has previously been established that Walsingham operate a robust and thorough process of recruitment in order to safeguard the best interests of people living in High oaks. To balance the above comments we were consistently told by people who live in High Oaks that the staff team provide them with a good standard of care, are responsive and helpful. High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in High oaks can be confident that their needs and views are central to the way the home is managed. The home is improving and is now being well managed, although more robust monitoring of key medication records is required in order to ensure the continued well being of people living in the home. EVIDENCE: “Definitely an improvement since the new manager came” and “there is now light at the end of the tunnel” were some of the comments made to us in assessment of the current position of the home, following a particularly challenging period. When we talked to the manager we found that they are applying for registration with the CSCI. They have previously been registered in respect of another home and already hold the Registered Manager’s Award. Over the High Oaks (1) DS0000019422.V368826.R01.S.doc Version 5.2 Page 22 course of our visits and as we talked to people living in the home and to members of the staff team we found that the manager has already achieved significant progress, together with their staff team, over the past year. We received the AQAA from the home within the required timescale and the way it was completed gives confidence that the appropriate importance was attached to its completion. The AQAA provides detailed information about how quality and the care experience for people living in High Oaks are monitored and the care plan documentation as it is evolved and improved should make the person centred focus of the home’s operation even more clear. We saw records of meetings for people who live in the home and also staff meetings. As indicated elsewhere in this report currently staff meetings are only for the very few permanent staff and do not include any regular agency staff. Although the standard of record keeping is generally quite good, the failures notes in the medication records are important and in order to fully protect people living in the home, a more robust system of monitoring must be introduced. Whilst we were visiting the home there were two occasions where staff were ‘slapped’ by a person living in the home, who had become agitated. When we looked at records of incidents we found that this has been well recorded, but has occurred increasingly frequently. An updated risk assessment was found to be in place, setting out triggers for this behaviour and strategies for dealing with it. We were told that meetings were being held with relevant health and social care professionals to review the situation. We looked at the records kept for the monies spent by staff on behalf of people living in the home. This is subject to internal and external checks and appeared to adequately safeguard the interests of people living in the home. High Oaks (1) DS0000019422.V368826.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 Adults 18-65 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 X 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 2 32 2 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X X 2 X High Oaks (1) DS0000019422.V368826.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 Standard YA20 Regulation 13(2) Requirement In order to protect people living in High Oaks that rely on staff to administer their medication for them the manager must put in place a system of monitoring for medication administration that quickly identifies where errors have occurred and takes appropriate action to rectify any error found. Timescale for action 31/07/08 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 Refer to Standard YA1 Good Practice Recommendations In order to make sure that any issues around diversity and equality are identified, the home’s documentation should be reviewed to make sure that it explicitly and adequately addresses equality and diversity throughout. To make sure the home can correctly store controlled drugs where these are prescribed for people living in High Oaks, the manager should ensure the controlled drugs cabinet and register meet the requirements of the Misuse of Drugs Act 1971. DS0000019422.V368826.R01.S.doc Version 5.2 Page 25 2 YA20 High Oaks (1) Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 High Oaks (1) DS0000019422.V368826.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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