Inspection on 30/08/07 for Malmesbury House

This inspection was carried out on 30th August 2007.

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

The inspector 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

Malmesbury House 25/08/09

Malmesbury House 29/08/08

Malmesbury House 15/05/06

Malmesbury House 02/11/05

Malmesbury House 18/04/05

Malmesbury House 11/01/05

Malmesbury House 20/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Malmesbury House Malmesbury House 18 Beauchamp Road East Molesey Surrey KT8 0PA Lead Inspector Vera Bulbeck Unannounced Inspection 30th August 2007 10:30 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 Malmesbury House DS0000013709.V348514.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. Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Malmesbury House Address Malmesbury House 18 Beauchamp Road East Molesey Surrey KT8 0PA 020 8783 0444 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) Mrs Mary Gajraj Dr H Gajraj, Dr N Gajraj Mrs Mary Gajraj Care Home 19 Category(ies) of Dementia - over 65 years of age (14), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (2), Physical disability over 65 years of age (1), Sensory Impairment over 65 years of age (1) Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the fourteen (14) service users in category DE(E) (Dementia - over 65 years of age), one (1) named person may also fall within category SI(E) (Sensory Impairment - over 65 years of age). 15th May 2006 Date of last inspection Brief Description of the Service: Malmesbury House is a large detached property situated in a residential area close to the local shops of West Molesey. The accommodation is on three levels, ground floor, first floor and second floor. All floors are accessible by a passenger lift. The majority of the bedrooms are of a good size, and are single bedrooms with en-suite facilities. A number of service user’s bedrooms situated on the ground floor have access to the garden. The home is set in spacious and well-maintained grounds, which are readily accessible to the service users. There is a large nicely furnished conservatory used by service users mainly for activities. The conservatory is also used, as a quiet area for service user’s to entertain relatives and friends. There is ample car parking at the front of the premises. The fees range from £575.00 to £750.00 per week. Items not covered by the fees include hairdressing, newspapers and magazines, chiropody and personal items. Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took place over seven hours and thirty minutes commencing at 10.30 am and ending at 18.00pm. Mrs V Bulbeck, Regulation Inspector carried out the visit. A full tour of the premises was undertaken. Four care plans were sampled and the care observed for the four individuals. The inspector spoke with a number of service users. The inspector was also able to speak to two relatives, and several members of staff were spoken to during the visit. A number of records were observed. The registered manager Mrs Mary Gajraj has had an accident and was not available. The deputy manger was in charge of the home on the day of the site visit. A new manager has been appointed and commenced work on 20th September 2007 and intends to become the registered manager. However, the manager was not available on the day of the site visit. There were fifteen residents living in the home on the day of the site visit and there were four vacancies. The inspector would like to thank the residents and staff for their co-operation and hospitality during the inspection. The service users living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. What the service does well: Resident’s views are continually sought to improve the service the home provides. Regular meetings with residents are undertaken; the registered manager or deputy manager chairs the meetings. Minutes of the meetings are undertaken to ensure residents comments made are taken seriously, and an action plan is in place. The inspector spoke to a number of residents; all were complimentary towards the staff, regarding the care provided and the staff team. Several residents living in the home stated they were happy to be living in such a nice place; they were well dressed and some stated they enjoyed their lunch on the day of the site visit. Lunch is served in the main dining area and one resident who was not feeling well has her meals in her bedroom. Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 6 The tables were nicely laid the food was plentiful and appeared appetising and nourishing and there is a choice of menu. The inspector spoke with a number of staff on duty on the day of inspection; staff commented they feel supported by the management of the home. Staff also commented they work well together and the team is stable, with very few changes in the team. The home was homely and welcoming and the majority of areas in the home were nicely decorated and furnished. Some residents had some items of furniture in their bedrooms, which they had brought into the home with them. 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. Malmesbury House DS0000013709.V348514.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 Malmesbury House DS0000013709.V348514.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 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident is only admitted to the home following a needs assessment to ensure that the home can meet the resident’s identified needs. The home does not offer intermediate care. EVIDENCE: A number of residents have been admitted to the home since the last inspection and pre assessments had been undertaken. These documents were found to be well documented, the resident, relative or care manager is involved where possible and signs the document to ensure the home is able to meet the residents needs, prior to admission to the home. The home has provided a service users guide to all residents and relatives on admission to the home. This was not checked on this visit, management of the home stated that the statement of purpose and the service users guide is reviewed on a regular basis to include any changes. Some relatives are also Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 9 provided with a copy particularly, if a resident is unable to be involved with the care provided in the home. The home does not admit residents requiring intermediate care, as the facilities required for the care needed are not available in the home. Malmesbury House DS0000013709.V348514.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 good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and documented in care plans. Resident’s healthcare needs are maintained. EVIDENCE: Four residents care plans were sampled and there was evidence that resident’s health, personal and social care needs had been identified and assessed. Care notes are documented but the notes need to be more informative and detailed. A copy of the care plan is kept in the main office to enable staff to use as a working tool. A number of risk assessments need to be updated for all residents living in the home. The deputy manager informed the inspector that the management are currently in the process of changing the care plans to be person centred planning. Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 11 Medication records were well documented and a list of staff signatures was recorded on the file. There needs to be a photograph of the resident on the MAR sheet. The qualified person on duty administers medication. The manager is maintaining a weekly check on the administration of medication to ensure there are no errors. Storage facilities were appropriate. There are no resident’s who are able to self medicate. The inspector provided a copy of the “Administration and Control of Medicines in Care Homes and Children’s Services” document. The home was still using the old document, which was changed in 2003. The residents spoken to confirmed that staff are respectful and knock on the door before entering. Observation by the inspector was some residents and staff has a good rapport. Residents stated they discuss any worries they have with their family. The inspector would advise the management of the home to seek the services of an advocate for any residents who do not have family or friends visiting them on a regular basis. Malmesbury House DS0000013709.V348514.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 good. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to maintain contact with family and friends. Meals are well balanced and varied, individual choices and preferences respected and special dietary needs catered for. EVIDENCE: The Majority of residents have contact with family and friends and the inspector had the opportunity to speak with two relatives on the day of the site visit. The relatives spoken to confirmed they are very happy with the home and one person stated, he had looked at other homes before seeing Malmesbury House and was happy they had chosen the home for his relative to live in. Discussion with the family member at the time of the inspection confirmed that he visits at least every week. Anther relative commented that she had spoken to the deputy manager about the clothes worn by residents are not always ironed and bed covers are not ironed. The deputy manager confirmed that she had dealt with this matter and had spoken to the relative, who said she was satisfied with the outcome. Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 13 It was also noted in the visitor’s book that there is a daily record of visitors to the home. Those residents who do not have family or friends an advocate needs to be involved. There is a planned monthly activity programme, which needs to be displayed on the notice board for residents to view. The dining area and lounge is mainly used for activities, also the conservatory. On the day of the site visit an activity organiser was undertaking arts and craft. A number of residents were busy painting. A musician visits the home on a regular basis and entertains the residents. Some residents prefer to sit and read or watch television. A number of residents stated they enjoy the activities and there should be more available. Management of the home has arranged several outings for the residents. In February three residents went to Garson’s farm for afternoon tea. In March four residents went to an Art Exhibition, May four residents went to Walton Playhouse and in June three residents went to Epsom races, watched a race and had afternoon tea before returning home. On bank holiday Monday a theatre production, Lights Camera Action was organised to entertain the residents with music from most loved movies and Just Us musical, has been booked for 20/09/07 to entertain the residents in the home. Residents confirmed they enjoyed the production. Several residents commented that the staff team are very good; one resident commented, “The staff are wonderful nothing is too much trouble”. Several residents confirmed on occasions they are able to go out with their relatives. The meals served in the home were nutritional in content and well balanced. The chef is involved with the menu planning, and seeks the resident’s views. The menu of the day needs to be displayed in various areas around the home for residents to see and all residents need to be informed of the menu. The chef was on duty at the time of visiting the kitchen and was able to demonstrate the procedures and the operation of working in the kitchen. Some residents require feeding and the inspector observed some staff feeding the resident’s; this can be a long process as some residents eat slowly. Malmesbury House DS0000013709.V348514.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. The home has a simple, clear and accessible complaints procedure. Service users are protected through receiving care by staff trained in safeguarding adults. EVIDENCE: There has been one recorded complaint in the home, the details of the complaint were not available as the complaint had been dealt with over the phone. However, the home should maintain a record of the action taken. The procedure for dealing with complaints was available which states any complaints would be dealt with within the 28-day time scale. The deputy manager was very clear on the procedure for managing any complaints and the outcome of the complaints. All residents are provided with a copy of the complaints procedure, which is available in the resident’s terms and conditions pack. All new residents are given a copy on arrival in the home. A copy of the complaints procedure is also clearly displayed on the wall in the hallway. The homes policies and procedures for the protection of vulnerable adults and a whistle blowing policy were in place and the inspector was informed the majority of staff has received the protection of vulnerable adults training. However, new staff needs to complete the training. The home needs to obtain Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 15 an up to date copy of Surrey Multi Agency procedures, the copy in the home was dated 2001. The home is still in the process of dealing with an allegation, which was referred to the Safe Guarding Team in November 2006. The deputy manager stated that Social Services are involved under Surrey Multi Agency procedures for the protection of vulnerable adults; the home has not had any contact with the Safe Guarding Team since 04/05/07. The inspector advised the deputy manager to contact the safe guarding team for further information and a decision. The Commission for Social Care Inspection have not received any complaints regarding the home since the previous inspection. Residents are encouraged to vote and some have been registered for a postal vote. Malmesbury House DS0000013709.V348514.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in the home are continuous in order to ensure a safe environment for residents. The home was observed to be generally clean. EVIDENCE: The environment is homely and welcoming all bedrooms were nicely decorated and furniture was of a good standard, rooms were personalised with some items brought into the home from the resident’s own home, or purchased by the residents to suit their new surroundings, for example; new televisions. The home has a maintenance person who undertakes jobs around the home on a regular basis, to ensure all areas in the home are meeting the health and safety aspects. There were some areas identified needing attention which were discussed at the time of this inspection which should be addressed by the Provider. In Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 17 particular a light in the airing cupboard which had a bare bulb and could potentially cause a fire. Issues relating to domestic cleanliness were pointed out to the deputy manager who requested the domestic person to deal with immediately. All staff should have appropriate clothing provided for serving food and staff require training in the area, food hygiene and infection control training. The garden at the back of the house is of a good size; the grounds are well maintained and nicely laid out. It was noted that residents are able to use the enclosed area of the garden, which is nicely laid out with tables, chairs and umbrellas. However, the inspector was informed that it has been too cold most of the time for the residents to enjoy the garden. It was noted that moss was growing on the patio area, this needs to be cleared to ensure the safety of residents walking and falling. Malmesbury House DS0000013709.V348514.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 numbers and skill mix of the staff meets resident’s needs. The home has a comprehensive staff recruitment and training programme which, incorporates all areas needed to ensure, as far as reasonably possible, that residents are in safe hands at all times. However, recruitment procedures needs to be improved. EVIDENCE: The staffing arrangements in the home include three care staff in the morning and two care staff in the afternoon. The manager is supernumerary; the domestic works form 10am until 2pm every day including Sunday. The chef works five days a week and at weekends an agency chef does the cooking. Recruitment procedures are being followed. All staff has been checked against the Criminal Records Bureau (CRB) and POVA checked before working in the home. Staff records were observed and found to contain relevant documents, including contracts and terms and conditions. However, new staff records have not been fully completed one member of staff has started work on a CRB from her previous employer and the management is waiting for her up to date CRB to be returned. It was also noted there were gaps in one member of staffs C.V. the deputy manager stated she would attend to this immediately. There is also a need to Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 19 have an up to date photograph of all staff on file, this information is clearly detailed in the Care Homes Regulations 2001, Schedule 2. The majority of staff has received (POVA) protection of vulnerable adults training and further training is ongoing. The home has 42 of staff with NVQ Level 2 training and above, this includes eight staff who have completed NVQ Level 2 and above. Six staff are in the process of NVQ Level 2 and above. The registered manager has identified training as a priority. A number of staff needs to attend food hygiene and infection control training. It was identified at the time of the visit that the deputy manager and a member of staff have attended equality and diversity training. The deputy manager informed the inspector that all staff are made aware of the differences in cultures and religion. The member of staff who attended the equality and diversity training informed the inspector that she had really enjoyed the course and felt she had learnt a lot and was able to inform the people she works with about the course. The inspector was informed that all staff are to attend the equality and diversity training in due course. Malmesbury House DS0000013709.V348514.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, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a monitoring system in place to seek the views of the residents. The health and safety of the residents needs to be reviewed by the management and staff of the home, to ensure residents are not put at risk. EVIDENCE: The deputy manager has been managing the home for the past year until a new manager was appointed in August 2007. Staff were complementary regarding the new manager and stated they feel supported. The manager had only been in post for seven days at the time of the inspection and staff felt there was not sufficient time to make a judgement. However, they did say management are very helpful. Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 21 A questionnaire (Customer Care Satisfaction) has recently been undertaken and was sent to all relatives, and professionals and residents to complete. Seven, feedback comment cards have been returned by residents, and twelve from relatives and two from district nurses. Information regarding the survey can be obtained from the manager. The Registered Provider needs to ensure that regular monthly visits to the home are undertaken in accordance with Regulation 26 of the Care Homes Regulations. The deputy manager has undertaken regular meetings with residents. Minutes of the meeting were well documented to ensure the home is meeting the needs of the residents, and an action plan was in place so that appropriate feedback can be given at the next meeting to ensure the views and comments made by the residents are taken seriously. A number of records were checked and some were found to be well documented and details were filed appropriately. The Registered Provider is recommended to ensure that all portable appliances which do not have a sealed plug are checked at least annually and records kept. This is to ensure the health and safety of residents. To ensure the health and safety of residents within the home the Registered Provider should ensure that a Legionella test is obtained for stored water, that the emergency call system, installed in 2006, is checked on a regular basis and there is an up to date gas certificate. To minimize the risks of food poisoning of residents the Registered Provider should ensure that a cleaning schedule be put in place in the kitchen including regular defrosting of the fridge. All food stored in the fridge and freezer should be sealed, labelled and dated and the chef attend a food and hygiene course. Resident’s finances are managed by relatives. The home would pay for any items that need payment for example hairdressing, an invoice would be sent to the family for payment to the home. Comment cards were sent out by the CSCI however; none had been returned to date. The inspector spoke with a number of residents and those spoken to were very complimentary regarding the home and staff. Malmesbury House DS0000013709.V348514.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 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 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 Requirement Full recruitment details must be obtained including an up to date photograph of each member of staff. The testing for Legionella must be undertaken. Timescale for action 21/09/07 2 OP38 13 21/09/07 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 3 4 5 6 Refer to Standard OP7 OP9 OP15 OP18 OP19 OP38 Good Practice Recommendations Care plans need to contain more detail regarding the resident and the care provided. MAR sheets need to include a photograph of the resident. Menus need to be displayed for residents to see. The home to obtain an up to date copy of Surrey Multi Agency procedures. The moss needs cleaning from the patio area. A cleaning schedule needs to be in place for the kitchen. The food kept in the freezer must be sealed, labelled and dated. Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Malmesbury House DS0000013709.V348514.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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