Inspection on 05/07/07 for Lancaster House

This inspection was carried out on 5th July 2007.

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

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

Other inspections for this house

Lancaster House 08/07/08

Lancaster House 29/06/06

Lancaster House 04/08/05

Lancaster House 21/04/05

Lancaster House 07/02/05

Lancaster House 06/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Lancaster House 2 Portal Avenue Watton Thetford Norfolk IP25 6HP Lead Inspector Ruth Hannent Unannounced Inspection 5th July 2007 09:15 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 Lancaster House DS0000027327.V345234.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. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lancaster House Address 2 Portal Avenue Watton Thetford Norfolk IP25 6HP 01953 883501 P/F01953 883501 annettehowarth@lancasterhousecarehome.co.uk 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) Mr Sarath Ekanayake Mrs Jeeva Ekanayake Mrs Annette Howarth Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Nineteen (19) Older People may be accommodated. Date of last inspection 29th June 2006 Brief Description of the Service: Lancaster House was originally built as officers quarters for the RAF and is situated near the entrance to the former barracks on the outskirts of the Breckland town of Watton. The barracks are no longer operational and have since become a private residential area. The house itself has been extended and adapted to provide residential care for a maximum of 19 older persons. The accommodation is all within single rooms. The 10 ground floor rooms all have en suite facilities. The upper floor is accessible by a stair lift and rooms in the older part of the house have wash-basins and share toilet facilities that are close by. The care home has a large and pleasantly appointed lounge dining room with 2 access points out into the rear garden. All the main doors into the house have ramped access. There is a private car park at the front of the building. Email sarath.ekanayake@btopenworld.com Fees £350 - £380 Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a period of five hours with the newly registered Manager. This report has been completed after looking at medication records, care plans, and training/personnel records. A tour of the building took place and residents, relatives and staff were spoken to. A meal at lunchtime was taken in the dining room and lots of observation took place. Prior to the inspection the Manager had completed an annual quality assurance assessment (AQAA) and four comment cards from residents had been received. All this information has been used to complete this report. Overall the care offered in the Home appears to be carried out well but some documented evidence is not in place to show all procedures for residents are taking place. Comments and conversations are all positive with just some suggestions from residents that need to be listened to. Residents appeared happy, talked about good care staff and felt the small home was a good home. What the service does well: What has improved since the last inspection? Since the last inspection the Home has had quite a few areas repainted and some carpets or carpet tiles replaced. The Home has purchased a new care plan recording system for residents. Although a slight improvement on the previous recording system there is still a need to complete these forms comprehensively to ensure they are tailored to the needs of the individual. The kitchen has improved greatly and the Home has achieved an award for the high standard. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 6 The Homes brochure and complaints procedure is much more available and on display for all to see. 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. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. 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. Potential residents do have a thorough assessment before they are offered a place to ensure the service can meet the needs of the person. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 9 EVIDENCE: Three residents were chosen at random to look at the assessment and admission process. The paperwork seen showed a good assessment initially had been taken and that this information had been placed in the assessment section of the standex care plan folder. On talking to two of the three residents they remember being visited by the Manager and also deciding with their family to live in the home. In the entrance is a nice informative brochure that is also shared with potential residents. The Manager was able to give a full explanation of how she assesses and receives information about potential residents to ensure the service can provide the care. An example of a recent inquiry was discussed and the reasons that the person could not be offered a place appeared justified. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 10 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plan records and medication administration procedures have some weknesses which could potentially place people at risk. EVIDENCE: The three most recently admitted residents had a new information/care plan folder. The system used is very clinical and does not specify in detail the care needs of the individual person. For example, ‘ needs all help with personal care’ with no guidance for the worker on how or what the resident may be able to do for themselves. The limited information on the actual care support required would not guide a new staff member to carry out the work fully. Another care plan assessment talked of ‘laying out the clothes’, which needed to be broken down into detail for this person who had no sight at all. (Requirement). The particular document did have information on weights that are carried out monthly and also a recording of bowel movements but as Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 11 this had not been completed properly with up to thirteen days without a recording then they are of little use. None of the care plans looked at had a moving and handling assessment in place. (Requirement) and none of the residents had any risk assessments in place even though the assessments stated that the person was prone to falls. (Requirement). Although the written documentation on care is limited it was noted that care staff do know the residents and on talking to at least eight residents during this visit they all stated that they get the care they need and the staff are very good at their job. On the day of the visit the Community Nurse was in the building and stated that the staff were very helpful and that her team called in regularly. Records of GP visits, continence advisor, chiropody and nurse visits are all recorded in the persons care plan folder. Residents, in conversation, said the support they receive from the community health team is good and the four comment cards received all ticked the positive answer boxes but had not written any extra comments. Concern was shared with the Manager over the administration of medication and the decisions made by the Senior staff team as to wether or not to issue medication even when the instructions on the MAR chart stated that the medication must be given. At all times, unless written that the instructions have been changed by the GP, medication must be administrated as stated. (Requirement). It was also noted that the Home has no audit trail for medication not held in the blister packs and could therefore be open to misuse. (Requirement) All extra medication is stored on shelves in the Managers office and not in a locked medication cupboard with a controlled drugs cabinet attached to the wall. The medication in this cabinet was counted and agreed with the record of medications written in the controlled drugs register. The residents do not have a photograph on the care plans or medication charts which is good practice and is a (Recommendation). Throughout the day residents and staff were observed and conversations overheard. The staff spoke appropriately and in a caring manner that was helpful such as explaining to a resident where on his plate the food was by using the clock face approach who had no sight, to asking would he like assistance to eat or could he manage. “After you have told me where it is I can now manage thank you”. Doors were knocked upon before staff entered and people were spoken to courteously. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The Home does not have procedures in place to enable residents to state their expectations and lifestyles that they would really like. Choice and control over their day-to-day lives are not always encouraged to empower all. EVIDENCE: The residents do have the opportunity to take part in activities with scrabble being a favourite at present. A sing along happens monthly and residents talked of their own stimulation such as word searches, conversations and reading the paper. The Home does not have a designated activities staff member and no cleaning staff and with quite a few dependent/poorly residents at the moment the staff are busy and have less time to offer than would be liked. One resident stated that since the Home has filled up (4 new residents arrived in one week) the staff have been a lot busier so they see less of them. The activities that have happened are recorded in a designated book to show who has participated. The Home does not hold residents meetings and residents do not actively become involved in what is happening within the Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 13 home. In conversation at the meal table 5 residents were not aware that a fete was taking place and had not been asked to help or be involved in any way. Another resident stated that she has requested that staff wear name badges because the residents forget their names but this has not happened to date. (Requirement). Families come and go regularly. This was noted by the entries in the visitors book and on the day of this visit 2 residents were visited with a cup of tea or coffee offered on each occasion. Residents also stated that the family and friends can call at any time. The Manager has tried to encourage families to be involved in activities but has not had many takers to date. A lunch was taken with residents on this visit. The meal was meatballs with broccoli, cauliflower, peas and potatoes with a sweet of strawberry cheesecake. A menu was on the table that showed lemon cheesecake not strawberry cheesecake and no one was offered a choice. I overheard a resident saying she wished she could have ice cream but this was not voiced to the staff. The meal was enjoyed by the majority but two residents stated they wished they had a choice on the day and that vegetables were served separately so they could choose the amount they have on their plate. Water was automatically in the glasses with no choice of what to drink or a jug to fill up the glass. On talking to the Manager it was understood that the only time choice is offered is if the residents states to the cook they do not like certain foods. (One lady stated she didn’t like fish so was given an alternative but she did not know what she was getting until it arrived). (Requirement). Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Any complainant should feel their concerns will be addressed and a satisfactory outcome achieved. Residents are protected from abuse. EVIDENCE: The Home had received one complaint since the previous inspection that was mentioned on the Homes own self-assessment document and was discussed fully with the Manager on this visit. The letter of complaint was seen and also the follow up letter from the complainant who thanked the Owner for dealing with the complaint so well and how pleased she was with the outcome. The Home also has a complaints procedure on the notice board at the entrance to the Home and loose leaflets available on how to complain for people to take as they wish. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 15 The last inspection asked the Home to ensure all staff were trained in the understanding of abuse. The Manager, on this occasion, was able to show all the training certificates achieved since last year of all the staff who have trained, with only newly recruited staff still to attend the training. Whistle blowing was discussed with the Manager who was clear about the “no secrets” in the Home. One staff member was also asked and would have no hesitation to discuss any concerns regarding potential abuse with the Manager or Owner. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home have improved and some are in need of further improvement. EVIDENCE: The Home has had a face lift in areas that at the last inspection were looking shabby. Walls have been painted in lighter colours and some carpets of carpet tiles have been replaced. The main kitchen has been improved greatly with new work surfaces, painted cupboards and window sill replacement. (These improvements have helped the Home win a Good Food Award from Breckland Council on 14/06/07). The areas are generally tidy and the gardens are well maintained. The fire equipment has all been serviced on the 15/02/07 with records seen. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 17 The Home has only one bath and one shower room. The assisted bath is aging and the surface has become cracked and glazed making it difficult to ensure the bath is clean and free from infection. With only the choice of one bath this should be in top condition and needs to be replaced. (Requirement). The shower in the new extension has a problem with mould around the bottom edge of the tiles and needs some work to improve this (Recommendation). The Home has just purchased a new stand aid and has a contract with Stannah and Arjo to service all the lifting equipment in the Home. (seen). The water temperature was checked on the bath and ran at a constant 40 degrees. All the bedrooms hold residents personal items and look comfortable. One lady in her room said how much she liked her room and the way the furniture was placed. Radiators are all covered for safety and two residents spoken said their rooms were warm enough. The Home relies on care staff to clean the Home as well as carrying out care duties. This showed in the general appearance of the more deeper cleaning tasks required such as cobweb removal or carpet shampooing. The care requirements of some of the residents is high, and takes time. The Home should consider a designated cleaner to allow care staff to concentrate on the care delivery. Comments from staff such ‘we have to spend too much time cleaning especially in the afternoon when we should be giving the attention to the residents’ to the resident who is saying ‘we see much less of the staff as the Home has filled up’. (See staffing). There were no unpleasant odours and general areas were clean. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The trained staff should be left to care and domestic staff should be in place to clean and launder to improve these standards. EVIDENCE: The 3 care staff on duty is adequate for the number of residents and the dependency of those residents (18 on the day of inspection) but does not take into account the fact that they have cleaning and laundry tasks to do as well. (In the afternoon/evening the care staff also have to prepare tea and clear up). Residents do look well cared for but would like to see more of the staff to assist with tasks when required. The Home needs to consider recruiting staff to carry out domestic duties, thereby allowing care staff to meet all personal, health and social care needs. (Requirement). Of the 14 care staff employed, 4 have NVQ 2, 1 has NVQ 3 and 5 more are about to begin the programme. In total three personnel files were looked at. The manager has been trying to get files up to date and on seeing the two recently recruited staff the relevant paperwork was found that included application, contract, 2 references, Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 19 passport and birth certificates copies and CRB. Some staff who have been employed for many years do not have all the relevant paperwork such as 2 references but all have CRBs or are about to have them renewed as they are now 3 years old. The new manager has worked hard on developing a training programme to cover all aspects of care for the staff team. A training company is now involved and a rolling programme of training is in place. Certificates held in each personnel file was seen and a copy of who had what training and when was shown. On the day of this visit the staff were having a fire training session in the afternoon. Each session is held twice to ensure all staff can attend. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality assurance, staff supervision and staff induction all need to improve in order to ensure the continuous improvement of the service. EVIDENCE: The Manager has recently been registered and the certificate is on display in the entrance hall. Progression is taking place on achieving the NVQ 4 qualification and RMA award at Norwich College, which was discussed during the visit and appears to be nearly completed. The Home has written a questionnaire to assess the level of quality offered that was issued to residents with only two returned out of the whole Home. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 21 The questions were worded so that residents could answer yes or no and although the form had an area for comments no one had written any. Relatives were not sent one to their home addresses and with no relatives or residents meetings taking place no proper form of quality assurance is taking place. Ideas on how to assess quality with interested parties was discussed with the Manager who will be planning an annual development plan, action and review process to work towards improving the quality of the service. (Requirement) The Home has not progressed since the last inspection with carrying out supervision at least 6 times a year. The only record on file is an annual appraisal that was carried out in June 2006 and is now overdue. (Requirement) The Home has all the relevant training in place to ensure that staff carry out their duties as safely as possible. On the wall by the kitchen is a much safer fire procedure with plans of evacuation and which rooms occupied. (seen) The COSHH regulations are on display and all chemicals are stored away safely. (seen). The Manager has been sending the relevant Regulation 37 notifications and has over the year contacted the Commission on infection control concerns. A copy of all accidents are written in an accident reporting folder and even non injuries are recorded in case an injury appears later. The Manager has been trying to induct two new staff over the past three months but has not managed to complete and is now looking at other sources to find a more user-friendly induction pack. (Requirement) Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 1 2 x 3 x 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x 1 x 2 Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15.1 15.2 Requirement Residents care plans must give clear individual details of the care needs and be reviewed regularly. All potential risks for individuals must be logged and ways to eliminate or reduce the risk must be recorded. Residents who are assisted with any transfers must have a moving and handling assessment The manager must ensure that all medication is administered as per the written instructions on the MAR sheet and any changes instructed by the GP mid month must be altered and signed by the responsible individual. The Manager must ensure there is an audit trail for all medication stored in the Home. Residents should be actively encouraged to make choices and be involved in the day to day life of the home Residents should have the meal offered with a choice offered on a daily basis. Timescale for action 01/10/07 2 OP7 13.4c 01/10/07 3 4 OP7 OP9 13.5 13.2 01/10/07 01/09/07 5 6 OP9 OP12 13.2 16.2 (m&n) 13.2 (i) 01/09/07 01/10/07 7 OP15 01/10/07 Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 24 8 9 OP21 OP27 13.4 (a) 18.1 10 11 12 OP33 OP36 OP38 24 18.2 18.1c The one bath in the Home needs replacing due to the poor condition of the surface. The Home must have sufficient staff on duty to cover all areas of work that include domestic cleaning needs as well as care. The Manager must ensure an effect quality assurance monitoring system is in place The Manager must ensure that staff receive appropriate supervision. The manager must ensure that new staff have a suitable and timely induction when first employed. Repeated requirement 01/11/07 01/10/07 01/10/07 01/10/07 01/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP21 Good Practice Recommendations The manager should have a photograph of each resident to ensure medication is administered to the correct person when new staff are employed. The shower room needs to be clear of mould around the tiles. Lancaster House DS0000027327.V345234.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Lancaster House DS0000027327.V345234.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. 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!