Inspection on 22/02/08 for Maiden Castle House

This inspection was carried out on 22nd February 2008.

CSCI found this care home to be providing an Good 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

Maiden Castle House 10/02/09

Maiden Castle House 20/08/07

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

CARE HOMES FOR OLDER PEOPLE Maiden Castle House 12-14 Gloucester Road Dorchester Dorset DT1 2NJ Lead Inspector Gloria Ashwell Key Unannounced Inspection 22nd February 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maiden Castle House DS0000069062.V360240.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. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maiden Castle House Address 12-14 Gloucester Road Dorchester Dorset DT1 2NJ 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) 01305 251661 01305 251102 maidencastle@care-south.co.uk www.care-south.co.uk Care South Post vacant Care Home 66 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (31), Old age, not falling within any other of places category (35) Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 10 service users may be accommodated for intermediate care in separate ground floor accommodation. A maximum of 5 of these service users may be between the ages of 55 and 64 years. May accommodate up to 10 service users aged between 55 and 64 years on admission and whose primary need on admission relates to their dementia. 20th August 2007 2. Date of last inspection Brief Description of the Service: Maiden Castle House is a purpose built property in a residential area of Dorchester. It is registered to accommodate people under the categories of Old Age, Dementia and Intermediate Care (Rehabilitation) services. Maiden Castle House is registered to Care South; a not-for-profit registered charity, (formerly the Dorset Trust) being an established provider of care services in the south of England. Care South currently has 19 care homes registered with the Commission. There are 66 single person bedrooms each with en suite hygiene facilities. The home comprises two floors divided into separate living units; Maumbury A and B are for physically frail people and the Intermediate Care Unit , providing short term care, is on the ground floor. Each unit has its own facilities, including a communal dining-room/lounge, kitchenette and sluice room. On the first floor are the Eggardon A and B Units; these are specially designed for the care and accommodation of people with dementia. These units include a range of communal areas, enabling residents to readily access their bedrooms and WCs. In the corridors are a number of built-in display cabinets containing household items from earlier years (e.g. the 1940s) to encourage the remembrance and interest of residents. Laundering of clothing and household linen is carried out at the home and arrangements can be made for chiropodists, opticians and other health and social care professionals to visit individual residents. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 5 On the ground floor there is an enclosed outdoor courtyard/patio area and on the first floor within the Eggardon Units there are balconies with safety glass. There are spaces for car parking at the front of the home. The fee range quoted in the service user guide at the time of inspection was £540 to £695 per person per week. Up to date fee information may be obtained from the service. Information regarding the subjects Value for Money and Fair Terms in Contracts can be obtained from the web link: www.oft.gov.uk A report entitled Care Homes in the UK - A Market Study is available on web link: http:/www.oft.gov.uk/NR/rdonlyres/5362CA9D-764D-4636-A4B1A65A7AFD347B/0/oft780.pdf Maiden Castle House DS0000069062.V360240.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 two stars. This means the people who use this service experience good quality outcomes. This inspection was a statutory inspection required in accordance with the Care Standards Act 2000. The inspection was unannounced; the inspector arrived at 9:30 on 22 February 2008, and later that day, at 10:30 was joined by an expert-by-experience who spoke to residents while the inspector concentrated on assessing documentation in conversation with the manager. The inspector toured the premises and spoke to residents and staff and documentation relating to care provision and the premises was discussed and examined. The duration of the inspection (inspector and expert-by-experience combined) was 6 ½ hours. The inspector and expert-by-experience observed staff interaction with residents and the carrying out of routine tasks. During the inspection, particular residents were ‘case tracked’; for example, for evidence regarding Standards 3, 7 and 8, records relating to the same resident were examined and the resident spoken with. The care records of five people who live at the home were examined in detail. The expert-by-experience was able to meet and speak with most of the residents both individually and in small groups in the communal areas. During this inspection compliance with all key standards of the National Minimum Standards was assessed. What the service does well: People considering moving into Maiden Castle House receive a full assessment and are provided with the opportunity to visit and spend time at the home to make sure that it is able to meet their needs. Discussion with residents indicated they are satisfied with the home; comments received by the expert-by-experience during the inspection indicated that they were pleased with their decision to move to Maiden Castle House, and were happy with the care they received from staff and with the activities and food. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 7 On the day of inspection the home was clean, comfortably warm and adequately staffed. It is well equipped, comfortable and maintained in good order. Each resident is properly cared for and has a documented plan of care. Food is well-presented, varied and nutritious. Staff are enthusiastic and competent, and receive training. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 8 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 Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 9 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): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user guide contains relevant information about the home providing prospective residents and their representatives with an accurate understanding of the people for whom the service is intended although the format of the information may not be suitable for service users who have specific needs for example those with impaired sight. Prior to admission, the needs of each proposed resident are assessed to ensure the home will be properly able to meet them. EVIDENCE: The Statement of Purpose and service user guide are provided to each resident and a copy is displayed in the entrance area. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 10 The records of a recently admitted resident included details of pre-admission assessment which had been carried out by the manager when the prospective resident visited Maiden Castle House to view the premises and meet residents and staff. Following pre-admission assessment of the prospective persons needs and circumstances the home sends a ‘Welcome Letter’ confirming agreement and ability to accommodate and care for them. Residents are able to visit and reside at the home for a trial period in order for both parties to determine whether the home is suitable and able to meet their needs and expectations. The purpose of the intermediate care unit is to provide a maximum of 10 persons at any one time with short term [generally ranging between 1 – 6 weeks] rehabilitation services in order to maximise their independence and enable them to return to their home. There was evidence to demonstrate that residents in the intermediate care unit had been properly assessed and referred to Maiden Castle House solely for short term rehabilitation purposes. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made using available evidence including a visit to this service. The health and social care needs of residents are fully met by suitably trained staff; doctors and other professionals visit as necessary and the home employs nurses and care workers who properly respect and promote the privacy and dignity of the residents. EVIDENCE: Residents said they are satisfied with all aspects of the home and feel they are in the care of competent and kind staff. Care provision is in accordance with a written plan of care for each resident thereby ensuring that staff have sufficient information upon which to base their care practice. Whenever possible, residents are actively involved in planning their own care and are encouraged to sign records to confirm their agreement. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 12 Care records of 5 residents were examined and contained risk assessments forming the basis for care plans and daily records describing the care of each resident. To ensure correct identification of residents, records contain a recent photograph of each resident. To further improve the standard of records it is recommended that specific guidance be provided to staff on the management of stomas, whether this be recorded in the care plan and/or a written policy/procedure. Medicines prescribed by doctors are safely stored and carefully administered to residents by staff trained in this work, thereby protecting residents from medicine errors. Medication administration records were properly kept indicating that residents receive prescribed medicines at the correct times and in correct amounts those wishing to do so can manage their own medicines in accord with a risk assessment process. It is recommended that medicines no longer in use be promptly returned to the pharmacy; at the time of inspection some Controlled Drugs obtained for a resident who had been discharged approximately 2 months earlier remained in storage. In the presence of staff residents appeared relaxed, confident and at ease; staff interactions with residents were of a friendly and considerate manner and the atmosphere throughout the home was calm and unhurried. Residents are treated with respect and their privacy and dignity is protected at all times. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 13 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. Residents are encouraged and assisted to maintain as much independence as possible. Social and leisure activities are varied and suited to the preference and ability of each resident. Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. Meals are appetising and of good quantity and quality. EVIDENCE: Most residents were spoken with during this inspection; all expressed satisfaction with the home, including the range of activities, meal provision, staff and premises. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 14 For 22 hours each week the home employs an Activities Organiser to arrange social and recreational activities; residents who wish to do so can become involved in simple household tasks such as laying dining tables. Displayed in each unit is a programme of activities including games such as Bingo, and one to one activities such as manicures. To ensure that the Activities Organiser is familiar with the needs and circumstances of each resident and can thereby design an activity programme to meet the individual preferences it is recommended that she be fully integrated within the care team, including the sharing of records and information, e.g. involvement at staff handovers and the care review meetings routinely arranged for each resident. Residents are given a choice at all mealtimes and are asked the day before to make their choice for the main meal the next day. Foods that have to be pureed for particular residents are kept as separate items on plates, to maintain attractiveness and to allow residents to experience different flavours. A resident who needs a special diet for diabetes said this was reliably provided. Residents who needed assistance to eat lunch were seated at the tables along with everyone else, with a member of staff seated next to them. The staff all took their time, not hurrying the residents and maintaining light conversation throughout the meal which took place in a relaxed and pleasant atmosphere. Visitors are welcome at any time and those present at the time of the inspection said they are always made to feel welcome and placed at ease by the staff. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 15 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. The complaints procedure provides information on the procedure to follow to persons wishing to make a complaint; all complaints are recorded and investigated and the home has implemented an adult protection procedure. EVIDENCE: To ensure residents and their representatives have access to the complaints procedure it is included in the service user guide to the home displayed at the entrance with a copy provided to each residents’ relative/representative. Residents know how to complain and feel confident that if they had concerns or complaints they will be listened to and taken seriously. The home keeps records of all complaints received and investigated. Since the last inspection two complaints against the home have been received; upon investigation one (relating to the provision of information to the representatives of a resident) was substantiated and prompt action was taken to rectify the shortcoming. The other complaint was not substantiated. The home has developed and implemented written policies and procedures for the protection of residents from abuse or neglect and provides all staff with Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 16 training in the understanding of abuse and their role in protecting residents from abuse in its many forms, including neglect. The policy and procedure document provides incorrect instruction on the reporting and investigation of alleged or suspected abuse, and in consequence staff have incorrect guidance and may thereby fail to properly protect residents from risks of harm and abuse. An associated recommendation is contained in this report. Training has been provided to all care service managers employed by the provider organisation on the recently introduced Mental Capacity Act to ensure accurate understanding of the relevant provisions. Care staff spoken with during the inspection said they think the standard of training available to them is very good and they are encouraged to undertake training in subjects that interest them. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Maiden Castle House provides a suitably equipped, well furnished and comfortable environment for the people living there. EVIDENCE: There are 66 single occupancy bedrooms with large en-suite facilities providing a shower, toilet, wash hand basin and grab rails. Communal rooms include lounge/dining areas, a faith room, activity room, a quiet/visitors’ room, a treatment room and a hairdressing salon. The total amount of communal space exceeds the requirements of the National Minimum Standards. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 18 There are 3 bathrooms, 2 shower rooms and 12 general use toilets, all suitable for us by people with impaired mobility. Aids and adaptations are available throughout the home e.g. grab rails, raised toilet seats. Residents with particular needs have their own personal equipment to assist with their independence. Residents are encouraged to personalise their rooms with furniture and general belongings as they wish and in agreement with the home. There is a passenger lift in the home providing level access to both floors. A personal alarm system is in place with moveable handsets in bedrooms and fixed points and pull cords in communal areas, including en-suites and bathrooms etc. Source of calls is displayed electronically on each unit. Staff carry pagers to enable them to identify and respond to calls quickly. On the days of this inspection the home was clean and there were no unpleasant odours. The laundry was clean and tidy and properly equipped; all laundry is carried out at the home. There was a very high standard of cleanliness throughout the home and there was evidence to demonstrate that basic training in infection control procedures is included within the home’s initial induction programme and ongoing training plan for staff. Sluice rooms are available for staff to dispose of and clean equipment and these areas are kept clean with suitable ventilation. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 19 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 enough staff to meet the needs of residents and to ensure their safety and comfort and maintenance of the good condition of the premises. Recruitment practices ensure the protection of residents from potentially unsuitable staff. The home promotes the achievement of nationally recognised care qualifications and supports staff to access the training they need to be able to properly care for residents. EVIDENCE: At all times the home is in the overall charge of an experienced person. Staffing levels are provided in accordance with the assessed needs of residents to ensure that at all times sufficient staff are available to properly meet their needs. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 20 Staff are enthusiastic about their work and feel they provide a good standard of care to residents and are properly supported by the management and training provision. The records of 2 recently employed staff members were examined and found to contain all essential information including an interview assessment, health details, two written references, evidence of identity and ‘Criminal Records Bureau check’ and induction training. At present approximately 59 of the care staff currently employed by the home hold a National Vocational Qualification in care so the home meets the associated Standard. There is an enthusiastic approach to staff training; there is an annual programme of training in relevant subjects to ensure that all staff have sufficient knowledge and understanding to properly care for the residents. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 21 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 home is well managed, suitably staffed and provides good standards of care to residents. A quality assurance system ensures maintenance of standards and involvement of service users. Policies and practices promote the health, welfare and safety of residents and staff of Maiden Castle House. EVIDENCE: Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 22 Since the last inspection the post of registered manager has become vacant; for approximately 6 months the home has been competently managed by the registered manager of another care home operated by the provider organisation, seconded to Maiden Castle House on a full-time basis. This person is supported by a deputy manager and between them they maintain a regular presence in the home; both are well respected and liked by staff and service users. During March 2008 the manager is to return to the care home to which she is registered; a new manager has been recruited for Maiden Castle House and is to commence employment during late February 2008 and will then apply to the Commission for registration. The home has ongoing systems for quality assurance; satisfaction surveys are periodically issued and the provider organisation is at present developing an extensive system for internal audit, designed to ensure that good standards are maintained in all aspects. This system is at present implemented at two ‘pilot sites’ and after completion of this testing will be introduced to all care services operated by Care South, including Maiden Castle House. There is a selection of clear and appropriate policy and procedure documents, including those for care provision, management and the premises. Records of fire alarm tests, staff training and drills were in order. The home does not act as appointee for any of the residents living at the home. Money held for residents is securely stored and there are procedures in place to safeguard the residents interests. Staff trained in First Aid and health care are on duty in the home at all times. All staff are supervised and a system of appraisal is planned for introduction later this year. Records are kept of all accidents and there is subsequent investigation, review of the care plan and periodic audit to identify any trends e.g. time, place, person, activity. Details of equipment servicing and maintenance were provided to the Commission in advance of the previous inspection in a questionnaire. The inspector examined some records to verify this information and accordingly recommended that the testing of water commenced during November 2008 be completed and the fire safety assessment be extended to include a detailed escape plan including reference to the currently accommodated residents. Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 23 There is a written assessment of the ‘Health & Safety’ of the premises and working practices to ensure that all aspects are thoroughly considered to promote the continued safety of all who live in, work at or visit the home. Maiden Castle House DS0000069062.V360240.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 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 4 X X X X X X 4 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 3 Maiden Castle House DS0000069062.V360240.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. Standard Regulation Requirement Timescale for action 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. 3. Refer to Standard OP7 Good Practice Recommendations Specific guidance should be provided to staff on the management of stomas, whether this be recorded in the care plan and/or a written policy/procedure. Medicines no longer in use should be promptly returned to the pharmacy. The Activities Organiser should be fully integrated within the care team, including the sharing of records and information, e.g. involvement at staff handovers and the care review meetings routinely arranged for each resident. The policy and procedure for the management of alleged or suspected abuse of vulnerable adults should be amended to ensure that every such concern is promptly reported to the Commission and to the local Social Services office, in accordance with established protocols for safeguarding vulnerable people. OP9 OP12 4. OP18 Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 26 5. 6. OP38 The testing of water commenced during November 2008 should be completed. The fire safety assessment should be extended to include a detailed escape plan including reference to the currently accommodated residents. OP38 Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Maiden Castle House DS0000069062.V360240.R01.S.doc Version 5.2 Page 28 - 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!