CARE HOMES FOR OLDER PEOPLE
Hollybank 27 Park Road Southport Merseyside PR9 9JL Lead Inspector
Mrs Joanne Revie Unannounced Inspection 8th November 2006 10:00 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 Hollybank DS0000017242.V319397.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. Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hollybank Address 27 Park Road Southport Merseyside PR9 9JL 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) 01704 530748 Mrs Ann Mallinson Mrs Ann Mallinson Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16), Terminally ill (2) of places Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 16 OP and up to 2 TI Date of last inspection Brief Description of the Service: Hollybank is a privately owned Care Home providing nursing care for 16 older Service users. The Registered Provider and Registered Manager is Mrs Ann Mallinson. Accommodation at Hollybank comprises of 10 single bedrooms with 1 ensuite and 3 double bedrooms with 1 en suite. Hollybank is situated in a quiet residential area of Southport close to the town centre, local amenities, the beach, Hesketh Park with good public transport links. The home consists of a four-storey building with a large garden at the front and small patio to the rear. The home has a passenger lift and wheelchair access. Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The visit was unannounced and took place over seven hours over two days. Discussions were held with six residents and tow visitors. Discussions were also held with staff and the owner of the home. Their views have been reflected in the summary section of this report. A variety of documentation was viewed during the visit, which is referred to in the relevant evidence sections of this report. The weekly charge for living at the home is £463.00 per week. What the service does well: As this is a relatively small home staff and residents know one another well and staff are able to offer personal touches (such as using and having your own cup), which helps to promote a very homely atmosphere and gives the feel of a domestic house. The owner who is a registered general nurse and also the manager of the home lives on the premises and is very involved in delivering care to the residents. This means that she can ensure that residents are receiving the care that they need and staff are delivering care in the way that they should. All residents and staff spoken with commented positively on her ability to run the home. One member of staff stated” she spoils them rotten” another stated,” Nothing is too much trouble”. The owner will be referred to as the manager for the remainder of this report. The manager undertakes assessments on all new residents who have expressed an interest in living at the home, This means that the residents have the opportunity to meet with the manager and the manager can decide whether the home can meet the needs of the resident and also plan for admission to take place. This reduces the risk of the resident moving to a home that can care for them properly. Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 6 One resident who has recently moved to the home stated that “ It was nice to see a friendly face- it stopped me worrying, they were very nice to my family and they’re happy that I’m being looked after properly”. Each resident has a care plan that they have agreed to. This shows that residents are consulted about the care that they receive. Staff know the residents well and understand their prefences and usual routines. Residents appeared well cared for and believe that the home offers a very good standard of care. Residents commented, “ Staff are marvellous, very kind- they always help me” and “ the staff are super”. Staff are quick to respond to changes in the residents health and contact appropriate health care professionals when the need arises. They are respectful to the residents and pay particular attention to assisting with grooming to promote their dignity. A visitor commented” dad always looks lovely were so pleased he’s here”. The home offers a variety of activities and due to its size is able to give flexible support and flexible meal times to enable residents to go out when they choose. Visitors are made welcome and feel involved in the residents care. One stated” I can come whenever I want- its home from Home” Residents enjoy the food they’re offered and due to the size of the home residents individual choices are catered for. Residents commented that the food is “ very tasty” and “`We’re given good stuff- the food is always great”. Residents and visitors know how to complain about the service but seldom do, as staff quickly addressed small concerns. One visitor stated “yes I know how to complain but Ivey no need- everything is perfect “ residents name” wants for nothing.” The home is clean warm and comfortable and is furnished like a domestic house, which promotes a very homely atmosphere. Residents are encouraged to personalise their bedrooms, which adds to the homely atmosphere. A long-standing team of staff are employed who have received training to care for the residents. One member of staff stated” I love it here” another commented, “ I wouldn’t work anywhere else”. This shows that staff are happy in their employment and are therefore more likely to stay which enables residents to receive care from staff who know them well. Surveys are sent out to residents asking for the views of the service on a six monthly basis. This shows that the manager is interested in their views. An outside quality assurance assessment also takes place. The home has been awarded five stars, which is the highest accolade under this system. Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
Although staff know the residents very well, the information that they have stored to memory must be included in the residents plan of care. Some care records require greater detail. Emphasis should be placed on resident’s preferences, treatment and state of wounds and activities which they would like to take part in. Records should also be re introduced showing which activities residents have taken part in Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 8 Concerns were identified around the management of medications. Many of the issues could be identified through regular auditing and addressed with individuals concerned through supervision (one to one time with senior member of staff). The manager should consider fixing the ceiling tiles of the first floor bathroom and redecorating the ground floor bathroom with the provision of better lighting Although new staff are receiving a structured induction this should be reviewed to ensure it meets the National Training Organisation guidelines and recommendations. The manager must ensure that the fire alarm is tested regularly to ensure it is in working order. 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. Hollybank DS0000017242.V319397.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 Hollybank DS0000017242.V319397.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): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Each resident has a full assessment, which clearly reflects their needs, and residents feel assured that their needs will be met. EVIDENCE: Three sets of assessment documentation were viewed and a discussion was held with the manager. The manager explained that she undertakes the majority of assessments however a full time Registered general nurse who is undertaking a management in care qualification has also become involved in this process. Three sets of assessment documentation were viewed which showed that assessments are undertaken focusing on the resident’s wellbeing, needs and preferences. Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 11 A discussion was held with a resident who had recently moved to the home who confirmed that staff had visited prior to admission taking place. The resident stated that it had been nice to see a friendly face and that this had been reassuring. Hollybank DS0000017242.V319397.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): 7,8,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Each resident has a plan, which shows that they have been consulted about their care. Staff know the residents personal preferences but don’t always record this information. Outcomes show that residents are well cared for and residents believe this to be true. Audit trails in documentation need much greater development to support this outcome particularly around the management of wound care. Residents are treated with respect and dignity Medication management needs to be strengthened to ensure medications are managed safely. EVIDENCE: Three care plans were viewed. Each contained instructions regarding the needs of the residents.
Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 13 One contained the details of the resident’s preferences regarding care but two didn’t. Staff are undertaking dependency levels on each resident on monthly basis to determine whether needs are changing. Staff confirmed that action is taken regarding the outcome of these. Evidence was viewed which showed that staff consult with residents/representatives regarding their plan of care and discussions with staff showed that even if the care plans didn’t reflect preferences they were very aware of how each resident wished to be cared for. Staff contact other health care professionals should a resident needs change. An example of this was wound care. It was evidenced that staff had promoted wound healing however this could only be determined by viewing wound care records that a tissue viability nurse had written following a visit to the home. Staff were recording phrases such as “ sore found” and “ dressing changed” but no written details could be found regarding the size, type and treatment of the wound. Daily records showed that staff were quick to contact G.P.s when deterioration in health occurs. All residents spoken with (6) reflected very positively on the standard of care that they receive. Risk assessments have been developed around the use of bedrails for those residents who are prone to falling. Risk assessments are also undertaken to identify the risk of pressure sores developing and the risks of malnutrition occurring. Outcomes of health care showed that residents are well looked after. 6 residents spoke very positively about the care that they recieve. Records showed that chiropodists, opticians, doctors and dentists visit the home as and when required. Medication management was assessed. The home has a suitable medication trolley, which was viewed, and records relating to receipt, disposal and administration (MARS) were also viewed. Staff had recorded handwritten instructions for one resident and this had been signed buy one staff member. Staff had recorded the amount of medication that had been received into the home but not the date that it had arrived. Some gaps were evidenced in the MARS` so it could not be determined whether residents had received their medication at those times. A stock check of Tamoxifen 20 mgs daily was carried out. The amount in the box did not tally with the amount given on the MAR. Homely remedies are administered at the home. A discussion with the manager revealed that initially G.Ps had been contacted to approve this but that this had not been repeated for some time. Drug disposals are recorded on the reverse of MARs but records showed that staff who undertake this were not signing their name so no audit trail was available to show who had done what. The manager explained during discussions that this is carried out by two members of staff. A contract was viewed which showed that a clinical waste collection regularly occurs at the home. Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 14 Staff were observed to knock on bedrooms doors before opening. All residents appeared smartly dressed with attention being paid to personal hygiene and grooming. Two visitors confirmed that the residents that they visited always looked well cared for. All residents spoken with confirmed that they believed that staff respected their privacy and dignity. A tour of the environment showed that each double bedroom had screens to enable staff to make a private area for the resident when needed. Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A range of activities is offered which are suitable to the needs of the residents but records need to be developed to evidence this further. Residents are encouraged to take part in activities outside the home. Staff offer choices to the residents around the usual activities of daily living. EVIDENCE: An activities rota was displayed in the hall of the home, which give details of what activity was happening when. Records of activities were viewed which were completed to a variety good standard but recording had stopped during last summer. Staff explained that this was because the activities organiser had changed. Residents spoken with (6) believe that there are sufficient activities within the home and that they are free to join in or not. Two care plans viewed stated that the resident should be encouraged to join in activities but not which ones or which ones they enjoyed. Viewing the visitor book and a discussion with staff and the manager confirmed that links have been developed with local clergy of different denominations and that they regularly visit the home and spend time with those residents who wish to meet with them.
Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 16 The six residents spoken with stated that their visitors were always made welcome by the home. Viewing the visitor’s book showed that visitors visit at a variety of times through out the week. Residents are supported to take trips out outside the home. One resident is supported to visits her relatives on a weekly basis and is provided with a late meal on return. During the visit staff were overheard offering a variety of choices to residents around were they would like to sit, food and T.V programmes/. All residents spoken with confirmed that staff offered choices around bed and rising times and clothes that they would like to wear. A menu was on display within the home. A hot cooked meal is provided at lunchtime with tea being lighter. The nutritional needs of patients are identified within care plans. Staff were observed supporting residents who required assistance to eat in a quiet dignified manner. Discussions with and viewing records showed that the cook is able to provide specialised diets for those residents who require it. The freezers were noted to be well stocked. Food is supplied by local suppliers as well as shopping at local supermarkets. The kitchen is domestic in size yet is well equipped and reflects the numbers living in the home. The cook has attained an Intermediate Food Hygiene Award and a certificate was available to confirm this. A small dining area is available for those who wish to use it on the top floor of the home however meals were served in the lounge or within bedrooms as preferred. The meal served on the day of the visit looked appetising and residents commented that it tasted nice. Discussions with all residents and visitors confirmed that they believe that the food offered is of a good standard and is cooked well. The cook makes nutritious soft puddings by adding nutritional drinks to fortify them with extra vitamins etc which reflects good practice. The cook revealed that herself or the manager prepares all meals. A copy of the safer food better business manual, which has been supplied by the Environmental Health Food Safety officer, was in use, which also reflects good practise. Meal times can be flexible due to the size of the home. One resident is regularly provided with a late supper on return from visiting relatives. Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents and relatives know how to complain and because staff are approachable, only ever need to raise small concerns which are quickly addressed. Staff have the skills to protect vulnerable adults from abuse. EVIDENCE: A discussion took place with the manager. A complaints book was viewed which was blank, as no complaints have been made to the home or to CSCI. A copy of the services complaints procedure was viewed which was found to be clear and gave the reader details of timescales. 3 residents confirmed that if they had concerns they would talk to the manager. Another three confirmed that they would talk to any of the staff if they had a concern. A visitor confirmed that they knew what to do if they were unhappy but explained that this was unlikely and everything was so good. The home has acquired the most recent copy of the local authorities guidelines for protection of vulnerable adults since the last inspection. A copy of a whistle blowing policy was also viewed. The manager explained that staff cover key policies such as these during induction. Staff training records showed that staff have undertaken training in prevention of abuse.
Hollybank DS0000017242.V319397.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): 19,24,26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is a clean comfortable place to live. Bedrooms are furnished with resident’s personal possessions, which add to a homely feel. EVIDENCE: A tour on the environment was undertaken which included viewing a selection of resident’s bedrooms. Bedrooms contained personal affects of the residents who resided in them. This gives the home a very homely feel. The home has one large communal lounge on the ground. Quiet areas have been created on the top floor for residents to use if they wish to receive visitors in private. A passenger lift is available to all floors. Generally the home is in good decorative order however the ceiling to the first floor bathroom requires attention to the tiling and the bathroom on the ground floor appeared poorly lit and was in need of redecoration.
Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 19 The manager explained that redecoration occurs on an ongoing basis and that plans were underway for the kitchen to be redecorated shortly after the visit. Domestic staff are available on a daily basis to clean the home. All areas viewed were warm clean and smelt pleasant. The home has a laundry room, which is equipped with an industrial washing machine and dryer. All sluices and bathrooms viewed contained liquid soap and paper towels for hand washing. Hollybank DS0000017242.V319397.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): 27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home employs a regular team of staff according to the needs of the residents. Staff are trained and have the skills to ensure residents are in safe hands. Robust recruitment processes are in place to ensure new staff are “ fit” for the role. Staff receive training to meet the needs of the residents. EVIDENCE: Viewing off duties showed that the home employs a regular team of staff. Staff stated that turnover is very low and all staff spoken with (4) confirmed they were very happy working at the home. The off duty is organised so that an overlap of staff occurs in the afternoon. Past inspection reports show that the staffing levels increase if the residents needs increase. The manager confirmed that this was true. 16 staff are employed at the home. Eight of these are registered general nurses. Four staff have completed NVQ training. The manager has completed the registered managers award and another RGN is undertaking a level 4 management qualification. Another member of staff was undertaking NVQ training at the time of the visit.
Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 21 Staff files showed that the manager ensures that staff are recruited in line with the Care Home regulations 2001. New staff undertake a structured induction. A completed induction was viewed and it showed that key areas of care are covered including key policies. It could not be determined whether this induction met the recommendations advised by the National Training Organisation and TOPPS and this was discussed with the manager. An advert was viewed in the office of the home informing staff of forthcoming manual handling training and fire safety. A training matrix was not available however as the home employs a small team of staff the manager keeps records of who undertook what training when. Staff Files viewed showed that staff have undertaken training in palliative care, resuscitation techniques, abuse awareness, first aid and drug administration. Hollybank DS0000017242.V319397.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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is “ fit” to manage the service.Residents are supported to express their opinion of the service. EVIDENCE: The manager is the owner of the home and lives on the premises. She is a registered RGN. The manager is very involved in the day-to-day running of the home and carries out care delivery, cooking and also acts as key worker for some residents. The manager confirmed that she has completed and achieved her registered managers award. Residents and staff commented positively on her ability to manage the home.
Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 23 A quality assurance report was viewed. This had been undertaken by an outside agency and reflected very positively on the service. The service achieved five starts, which is the highest award that this process can give. As well as this the manager sends surveys out to residents every six months to enable them to express their opinion of the home. The manager manages monies for two residents. The other residents have representatives who act `as appointee. Clear records were in place, which showed how much money had been received and how and when it had been spent. All withdrawals are signed by the member of staff and agreed by the resident. No Heath and safety issues were identified during the tour of the environment. Accident records were viewed which were completed to a good standard and showed that the manager audits any accidents that occur in the home. Registered general nurses have been trainined to undertake risk assessments for manual handling and these were available in the three care plans viewed. Fire equipment and associated documentation was found to be current however records showed that the fire alarm had not been tested since August 06. All hoisting equipment had been serviced including the passenger lift. The kitchen was clean, tidy and organised and staff are recording fridge and freezer temperatures to ensure food is stored at the correct temperature. Portable appliance testing was carried out in June 06. Current Gas and Electrical safety certificates were also available. Hollybank DS0000017242.V319397.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 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 3 X 3 X X 2 Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 25 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 3 Standard OP7 OP38 OP9 Regulation 15. - (1) 23. (4)(c) (ii) 13. -(2) Requirement Timescale for action 31/03/07 Care plans must be developed further to include resident’s preferences and social needs. The registered person must 04/12/06 ensure that the fire alarm is tested on a regular basis. The registered person shall make 31/12/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hollybank DS0000017242.V319397.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Hollybank DS0000017242.V319397.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
