Inspection on 18/03/09 for Holly Tree Lodge Care Home

This inspection was carried out on 18th March 2009.

CSCI found this care home to be providing an Adequate service.

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

Holly Tree Lodge Care Home 13/08/08

Holly Tree Lodge Care Home 24/08/06

Holly Tree Lodge Care Home 01/12/05

Holly Tree Lodge Care Home 15/12/04

Holly Tree Lodge Care Home 12/07/04

Holly Tree Lodge Care Home 12/01/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Parkmanor Residential Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Holly Tree Lodge Care Home 3 Eastgate Scotton Gainsborough Lincs DN21 3QR Lead Inspector Doug Tunmore Unannounced Inspection 18th March 2009 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Holly Tree Lodge Care Home DS0000034136.V374600.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. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holly Tree Lodge Care Home Address 3 Eastgate Scotton Gainsborough Lincs DN21 3QR 01724 762537 01724 764469 htlcare@btconnect.com 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) Staywood Limited Mrs Pamela Ellen Timmins Care Home 40 Category(ies) of Dementia (17), Dementia - over 65 years of age registration, with number (17), Learning disability (1), Old age, not falling of places within any other category (22), Physical disability (1) Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users in category DE must be aged 50 years and over in Holly Tree Lodge Residential Care Home The bed in Holly Tree Lodge Residential Care Home in category LD is for a service user named in the Notice of Proposal to register dated 21st October 2004 To be able to admit into Holly Tree Lodge Residential Care Home the person of category PD named in Variation Application Number V36870 dated 17th November 2006 No person to be admitted to Holly Tree Lodge Residential Care Home in categories OP, DE, DE(E), LD or PD when 40 persons in total of these categories/combined categories are already accommodated in this home. 13th August 2008 Date of last inspection Brief Description of the Service: Holly Tree Lodge provides nursing and personal care for up to 40 people, 17 of whom who have dementia requiring nursing care and are accommodated in a new purpose built unit. On the day of the inspection there were 35 people living in the home. The purpose built, single storey unit for people with mental illness of old age provides accommodation for 17 people in 15 single bedrooms and one double room. All bedrooms are en-suite with 2 having showers. This unit also has one lounge and one dining room. There is a garden area leading off from the lounge. Accommodation in the main building is on two floors and provides 4 double bedrooms and 15 single bedrooms, none of which have en-suite facilities. Accommodation on the first floor is served by a shaft lift. There are 2 lounges and a dining room. The home is also set in its own grounds. Twenty two people aged 65 years and over who require nursing care or personal care and one person aged 55 years who has a learning disability are accommodated in the main building. There are car parking spaces at the front of the home. The fees at the inspection visit on the 18/03/2009 ranged from £351:00 to £752:80 each week. Extras are for hairdressing, chiropody, personal newspapers and magazines. The provider makes no charge for escorting residents to hospital. Information about the home can be obtained from the Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 5 manager of the home. The service user’s guide is available from the manager and is kept in the office. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit and it formed part of a key inspection, focusing on key standards, which have the potential to affect the health, safety and welfare of people who use the service. Throughout this report the terms we and us refer to The Commission for Social Care Inspection (CSCI). We took into account previous information held by us including the previous inspection report, their service history and records of any incidents that we had been notified of since the last inspection. Before we made our visit the provider had returned the Annual Quality Assurance Assessment (AQAA). This gave us information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. The main method used to carry out the inspection is called case tracking, this includes following the care of a sample of people through their records and assessing their care. We spoke with three people who use the service. We spoke with one member of staff, the administrator, the handyman and a senior nurse. We spoke with three visitors as part of the information gathering process. The manager was present throughout this visit and was informed of the general outcomes. What the service does well: The home provides good information to prospective residents and relatives to help them make informed choices, and they are assured that the home can meet their needs through an assessment process. Residents benefit from a staff team who are friendly, helpful and mindful of the residents care needs. The home also has trained nurses who are on duty at all times. They enjoy a balanced diet based on their likes, dislikes and choices and benefit from a comfortable and hygienic environment that meets their individual needs. Comments made by residents were, ‘the staff are excellent, this is a happy place to be and I expect to be here for the rest of my life’. ‘I like the food and the company and everything about it. Other comments were, ‘ The staff treat us with respect and personal care is very good with one staff teaching a new carer how to shower me, I was very comfortable with the carers’. Three visitors also made complimentary remarks, with one stating that, ‘they treat my mum as a human being, residents are cuddled and comforted’. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: 1. Care plans must address the issues of individual residents privacy and dignity and how this is to be delivered. This would ensure that individual residents have their say as to how their privacy and dignity is to be maintained, given the daily routines that communal living imposes on them. 2. Not all people living in this home have a list of property or valuables that they came with. This must be undertaken to ensure that valuables can be accounted for and that residents are happy to keep them or not. 3. Care plans seen of three residents did not reflect person centred care planning. This must be introduced so as to ensure that residents are actively involved in their care plans, which would reflect the care that they need. 4. The manager was advised about the Mental Capacity Act 2005 and how this addresses the rights of residents. Care plans now need to reflect any assessments, decision making and planning if a person does not have mental capacity. 5. Admission forms must address fully any significant/specialist areas of care, which is required. They must also be fully completed. 6. Residents must be consulted about the type of activities they would like to have, with a record kept of their comments. 7. Medication must be signed for so that creams and ointments are given as per the prescription for the health of residents. Please contact the provider for advice of actions taken in response to this Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 8 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. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 9 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 Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 & 3 Standard 6 is not applicable Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The process for assessing residents is not untaken thoroughly enough nor is the information recorded in sufficient detail to enable an accurate decision to be made on whether the needs of the new residents can be met. EVIDENCE: The files of those residents who were being case tracked had admission forms which were not fully completed. The entries were brief and did not refer to specific and significant/specialist areas of care, which were needed. Residents files contained a letter from the provider stating that the home can or cannot met their needs. The manager confirmed that two files of residents who were being case tracked did not have completed pre-admission forms. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 11 Copies of assessments from Social Service departments are obtained and kept on residents files. Two visitors confirmed that they had received information about the home prior to the admission of their relative. They also said that a visit had also been made to the home and that the manager assessed their relative and that this process was very professional and calmly undertaken. Prospective residents are encouraged to take time before making the decision to move into the home on a permanent basis. Intermediate care is not provided. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Resident’s personal and healthcare needs are met so as to ensure their wellbeing. An accurate record is not always made of all medication given to people so as to ensure their wellbeing. The care planning systems are not person centred to ensure that the wishes of residents regarding their care are undertaken. EVIDENCE: We looked at the files of two people who were being case tracked and found that daily records written by staff were clear and records show that people have access to health care professionals. However, files did not fully evidence that care plans were person centred with residents views and needs recorded and acted upon. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 13 We looked at two residents files and found that both monthly and six monthly reviews were undertaken detailing any changes that might have been made in the care plan regarding the care to be delivered. Two visitors stated that, ‘we are regular visitors and their relative is always clean well dressed and she is treated as a human being’. They also confirmed that there are always a lot of staff present and that they are sensitive in ensuring that she is toileted regularly’. A third visitor confirmed that ‘her mother always has clean clothes, her nails are painted and is very happy at this home’. People confirmed that ‘they are treated with respect with regards to staff helping them with their personal care’. One carer stated that she is aware of safeguarding peoples dignity and privacy, whilst undertaking their intimate care needs. Two files of residents who were being case tracked were seen. Records did not evidence that residents had been involved in determining that their individual intimate care needs are being addressed in their care plans. We looked at resident’s medication sheets were seen and it was found that an accurate record is not always kept. One resident’s medication sheet had gaps, which had not been signed for, for creams. The senior nurse on duty confirmed that no residents are able to self medicate; she also stated that only nurses give medication to residents. The manager stated that they are moving over to a blister pack system in the near future, but gave assurances that an accurate record of creams given will be maintained in the future. The homes training plan showed that nurses had undertaken medication training (distance learning) in April 2007-8. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents experience a varied and appropriate activity programme, which would enable them to maintain an active social life. Residents are able to choose from a range of foods within a balanced diet. EVIDENCE: We looked at the comments made in the homes visitors surveys which showed that, ‘this is a friendly and well run establishment’, ‘I am very impressed the standard of care is first class’ and they look after my wife as if she were at home’. The activities notice placed in the entrance to the home that a variety of activities and outings take place (in the summer). Activities are arranged for March, June and July by the manager, included crafts and regular visits by entertainers. There is a visiting craft worker and a ‘motivation lady’ who visits to undertake projects with residents. Religious holidays are also celebrated and visitors are encouraged to join in. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 15 Residents confirmed that entertainers come to the home and that they join in with the singers. However, they commented that there is not much in the way of daily activities within the home. The manager confirmed that the activities organiser will be coming back shortly to undertake her weekly visits. There were no surveys available in the home, which showed what residents want in regards to daily activities. One carer stated that activities are usually undertaken on a Tuesday and organises arts and crafts. Visitors confirmed that they have seen entertainers at the home but not daily activities. However, they confirmed that birthdays are celebrated and that the manager put on a special buffet for her mother and all the family came. All visitors confirmed that staff are always friendly and welcoming when they visit. Two other residents confirmed that their religious needs were met by way of a vicar who visits from time to time. The inspector spoke to three people after lunch. They stated that they have a choice of meals and the food is very good. One specific comment was ‘I like the food and the company and everything about it’. The home has again been awarded a five star Food Safety Award. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear and gives people and their relatives the confidence that comments and concerns will be listened to. There is a robust adult protection procedure to safeguard residents. EVIDENCE: One carer commented that she knew what safeguarding was and what action should be undertaken if abusive practice came to her attention. She was aware of the types of abuse and what forms it could take. The carer was aware of the policies and procedures, which she has read. However, she had not undertaken safeguarding vulnerable adults training, but confirmed that she was undertaking level 2 in a National Vocational Qualification in looking after elderly people. The provider has the appropriate adult protection policies and procedures regarding the safeguarding of residents. We looked at ten personnel files of staff many recently employed and found that two had undertaken Criminal Record Bureau checks and the rest had Protection of Vulnerable Adults checks. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 17 None of the visitors or people seen on the day of the visit expressed any concerns to the inspector. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in clean, well-decorated, homely and safe accommodation. EVIDENCE: We looked at the maintenance book, which showed all those tasks undertaken relating to maintaining the fabric of the home. The maintenance man confirmed that there is a rolling programme of refurbishment. There are patio doors in the dementia unit, which open onto a small secure enclosed garden where residents who are able are encouraged to wonder in and out freely, under supervision, weather permitting. Residents told the inspector that they are more than happy with the environment and feel safe and secure. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 19 Risk assessments were completed for the use of bedrails. Information was also available for staff on how to use this apparatus safely. At a previous inspection one resident stated that the bedrails are very good and stop her from falling out of bed. Two residents stated that they liked their rooms and had brought memorabilia with them when admitted. They also said that their rooms are kept clean, dusted and tidy and there are no unpleasant smells. With the consent of residents we visited a number of rooms, which were personalised, clean and decorated to a high standard. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 adequately staffed with employees who were experienced, competent and trained to care for older people. EVIDENCE: Previous visits made on the 13/08/08 found that the manager had given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults, to all carers as part of their induction training. The training profile for 2008 was seen and showed that five care staff are trained to NVQ level two and five to NVQ level 2 and 3. Three carers are currently undertaking NVQ (National Vocational Qualifications). The training profile also showed that moving and handling, fire safety; MRSA relief, food hygiene and first aid training had been undertaken. The manager confirmed that there have been nine new staff members since December 2008. This she stated was due to over seas workers leaving. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 21 A carer confirmed that she had undertaken training at the home in 2008. The manager stated that she is awaiting her training programme for 2009 from the providers. The homes duty rota was seen and it was found to be an accurate record and showed that adequate staffing levels are maintained to meet the needs of residents. There is one nurse waking night staff and three carers. One carer stated that she felt that there were enough staff on duty and that a nurse is on duty at all times. She commented that this is a happy staff team. Staff were observed carrying out their duties in a sensitive and caring manner. Both residents and visitors felt that there were enough staff to meet their needs. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33, 35, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents risk assessments do not reflect all the safety issues relating to adaptations. The home is generally well managed meeting the needs of residents. People’s valuables are not protected due to inadequate procedures. EVIDENCE: The registered manager is qualified and experienced in running this home for older people. The operations manager visits the home on a monthly basis and undertakes an audit, with a copy of the report being left at the home. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 23 Observations made by the inspector during this inspection were that the manager spent a lot of time with residents and had an approachable manner. She was also proactive in addressing those issues raised in this visit and is to undertake changes as required. Staff made positive comments regarding the manager, with one stating that; ‘she is fantastic easy to approach; she listens to concerns of staff and spends time on the shop floor. We looked at one resident’s file and could not find a risk assessment or care plan detailing the care required for restraint undertaken by the use of a wheelchair support strap. There was no evidence that the use of this device had been discussed with the resident or her representative. The manager confirmed that she would address this issue immediately. The home conducts an in house quality assurance (QA) report. The quality assurance report is posted in the entrance hall for the information of residents and visitors. Relative’s surveys were seen and found to be positive in respect to the care provided to residents. We looked at two residents valuables/clothes form, which showed that a full record had not been made of either residents belongings. The manager stated that this was not acceptable and would ensure that staff-were made aware of this issue. The last residents/visitors meeting was held on the 23/01/08; there was a small attendance and no concerns were raised. The providers AQAA showed that; gas safety inspections have been carried out, electrical wiring checks, fire precautions checks, and portable electrical equipment checks. The manager stated that risk assessments are available relating to the home environment. Staff had been trained in Health & Safety, and Fire procedures to help ensure the safety of residents in an emergency. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 3 Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14(i) (a)(b)(c) Requirement A system must be established to ensure that there has been appropriate consultation regarding the assessment with the service user or a representative of the service user. A system must be established to ensure that individual residents care plans contain more detail about how to maintain peoples privacy and dignity. Timescale for action 23/05/09 2. OP7 12 (4)(a) 23/05/09 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 OP7 Good Practice Recommendations It is recommended that support plans include reference to the Mental Capacity Act, 2005 and the effects it has upon people’s lives. This is to ensure that their rights and choices are protected. Holly Tree Lodge Care Home DS0000034136.V374600.R01.S.doc Version 5.2 Page 26 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. 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