Inspection on 21/02/07 for Marion Lauder House

This inspection was carried out on 21st February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Marion Lauder House 15/01/06

Marion Lauder House 07/07/05

Marion Lauder House 11/11/04

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

CARE HOMES FOR OLDER PEOPLE Marion Lauder House 20 Lincombe Road Wythenshawe Manchester M22 6PY Lead Inspector Geraldine Blow Unannounced Inspection 09:30 21 February 2007 st 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 Marion Lauder House DS0000061036.V316809.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. Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marion Lauder House Address 20 Lincombe Road Wythenshawe Manchester M22 6PY 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) 0161 437 3246 0161 498 8241 mclark@careconcepts.co.uk Careconcepts Ltd Care Home 46 Category(ies) of Dementia - over 65 years of age (45), Learning registration, with number disability (1), Mental disorder, excluding of places learning disability or dementia (3) Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 46 service users requiring nursing care may be accommodated at any one time. Up to 46 service users aged over 65 and requiring care by reason of dementia may be accommodated. Within the maximum of 46, 3 named service users below 65 years of age requiring accommodation due to mental disorder ( excluding learning disability or dementia ) and 1 named service user requiring accommodation due to learning disability are currently living in the home. When these service users leave the service user category will revert back to Dementia, over 65 years of age (DE(E)). 15th January 2006 Date of last inspection Brief Description of the Service: Marion Lauder provides accommodation, with nursing care, for a maximum of 46 older people. The staff have expertise in caring for service users with dementia. The home was originally built as a residential care home by The City of Manchester but was purchased 13 years ago for its current use. The current owner purchased the home 2 years ago. It is about half a mile from the centre of Wythenshawe and is near a major motorway network. Major bus routes to Manchester, Stockport and Altrincham are within 400 yards of the Home. The home is on 2 floors. Bedrooms, toilets, and bathrooms are available on both floors. All lounges and dining rooms are on the ground floor. There is a passenger lift between the two floors. The charges for fees range from £347.00 to £669.50 per week. There are additional charges for chiropody, newspapers and hairdressing. Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 15 January 2006 and supporting information received in the pre-inspection questionnaire submitted by the home prior to this visit as well as several returned residents comment cards. This visit forms part of the overall inspection process and was conducted by 2 inspectors and took place on Wednesday 21 February 2007. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This inspection was also used to decide how often the home needed to be visited to make sure that it meets the required standards. As part of the visit time was spent with the residents who live at the home, observing how staff work with residents, discussions with staff and the homeowner and the home’s acting manager, assessing relevant documents and files and a tour of the premises was undertaken. What the service does well: The home offered a clean and pleasant environment for the residents who lived there. All received residents comment cards indicated that the home was usually clean and fresh, as did the homes hairdresser. From observations made and from talking to staff and the home’s mobile hairdresser it appeared that the privacy and dignity of residents was protected and that residents’ were able to have choice with regard to their every day life. The hairdresser said that from what he has seen when he visits the home the staff always protect the privacy and dignity of residents and that the residents were always clean and appropriately dressed. The staff were seen to be kind and patient with residents when carrying out their duties. Staff had a good knowledge of each resident’s individual needs and were constantly interacting with the residents and no request from a resident was ignored. The returned comment cards had positive comments regarding the care received and one returned comment card from a relative stated, “All the management and staff work in a very caring and attentive manner in respect of providing all patients required and nursing and domestic care needs.” The home carried out a pre admission assessment before a resident was admitted to the home to make sure that the home could meet the person’s Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 6 needs. Each resident has a detailed plan of care, which set out in detail, how that care was to be delivered. A choice of meals was available at each mealtime and the chef said that any reasonable alternative to menu could be provided. The kitchen staff were seen preparing an alternative meal for 2 of the residents. The chef said she talks to residents regularly about their likes and dislikes and the home had a four-week menu, which appeared to provide a balanced and healthy diet, and snacks were available at all times. Fresh fruit was always available and the chef said a trolley was left every evening with a variety of food for example bread, fruit and homemade cakes and scones. Feedback from the returned comments cards indicated that people were happy with the quality and quantity of food. Residents were seen to be enjoying their lunch and during the mealtime staff were seen providing 1:1 support to those residents who required additional help. The meal of the day reflected the information on the menu board. The home offered and encouraged training for staff to ensure that they had the necessary skills to meet the needs of the residents accommodated. Systems were in place to support residents or visitors to make a complaint and this was confirmed by feedback given in the returned comment cards. The owner of the home made himself available to both residents and staff throughout the visit and clearly had a thorough knowledge of all aspects of home and individual residents care needs. The residents and staff seemed to benefit from his presence and his ‘open door’ approach. This was confirmed by comments received in the returned comment cards. What has improved since the last inspection? What they could do better: To prevent any possible risk to residents the use of bed rails on resident’s beds should be assessed before they are used. A recommendation has been made regarding the recording of drinks that need to be thickened for residents. Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 7 The home provides a variety of activities for residents but it is recommended that the home consults with either the residents or their families and records the interests/hobbies that residents may like to participate in. 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. Marion Lauder House DS0000061036.V316809.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 Marion Lauder House DS0000061036.V316809.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): 3 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home undertakes an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: Prospective residents have a pre-admission assessment to ensure that the home can meet all of their assessed needs. The assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. For those residents referred through the Care Management arrangements, the home would obtain a summary of the Care Management Assessment prior to admission. The acting manager said that were possible prospective residents and their family/representatives were encouraged to view the home prior to making a decision about admission. Marion Lauder House DS0000061036.V316809.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans of care were in place to ensure that residents’ health and personal care needs were fully met and the systems and procedures for dealing with medicines appeared to protect residents. EVIDENCE: Random samples of files were inspected. Files were well organised and maintained, and divided into relevant sections, which made them easy for staff to use daily as a working tool. Care plans included pre-admission assessments, which identified the needs of residents. The plans of care were found to be detailed, informative and clearly set out the action that needed to be taken by staff to ensure that all aspects of health and personal care needs of the residents are met. Risk assessments had been included and the plans of care had been regularly reviewed to reflect Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 11 changing needs and current objectives for health and personal care. However it was noted that the risk assessments relating to the use of bed rails did not address the risk of using the bed rail but only the risk of the resident falling from the bed. Staff were observed delivering appropriate care and support to a number of residents in the home and it was evident that staff had a good understanding of individual care needs. From observations made during the inspection it appeared that the nurses and care staff treated the residents with respect and dignity. Medication Administration Record Sheets (MAR) were examined during this visit. It was noted that some medication, for example creams and a particular injection and had been prescribed, “use as directed” and “apply when required”. Although the manager was able to clearly describe the GP instructions and there was no evidence to suggest that the medication had not been given as intended this is not sufficient information to ensure the medication is administered as prescribed by the doctor at all times. Therefore the doctors’ instructions must be recorded. Some medication that had been carried over from the previous month had not been recorded and therefore a full audit trail could not be provided for that particular medication. It is recommended that medication carried over form the previous month is recorded on the MAR. It was noted that a prescribed thickener, which is used to thicken drinks and soups for residents with a swallowing impairment, had only been signed on the MAR sheet as being given 3/4 times a day. This did not accurately reflect the number of thickened fluids given to a resident. In order to ensure that residents’ care needs are being met it is vital that an accurate record is maintained of each drink / soup etc that has been thickened and any other liquid the residents have had to drink. Details of the recommended consistency of fluids, given by the Speech and Language Therapist, for individual residents should be readily available to all staff involved in the preparation of drinks / food for a resident. It was fond that eye drops, with a limited life span, had been opened and did not have a recorded date of opening and therefore an expiry date could not be determined. Medication with a limited life must clearly document the date of opening to ensure out of date medications are not given to residents. Waste medication was appropriately stored and there was a record of the medication, however it is recommended that 2 staff witness and sign for the disposal of waste medication. Marion Lauder House DS0000061036.V316809.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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities were provided and residents were able to maintain contact with family and friends. Meals served at the home were nutritious, well balanced and offered a healthy and varied diet for residents. EVIDENCE: The home operated an ‘open’ visiting policy and visitors could be seen in the privacy of the resident’s own room or in any of the communal areas. It was clear from observations that residents appeared relaxed and settled in their environment and there was a calm atmosphere throughout the day during this visit to the home. From observations and discussions with the manager it appeared that residents were encouraged to exercise choice and control with regard to their day-to-day lives. Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 13 Bedrooms had been made as homely as possible and several had been personalised with residents’ belongings brought in from their own homes. The home employs a part-time activity co-ordinator who was not on duty at time of visit. The acting manager said that residents or their relatives are informally consulted about hobbies or interests. It is recommended that this consultation be made more formal and that it is recorded to ensure that any activities provided suite the individual preferences of residents. Limited formal activities were provided at the home such as bingo and outside entertainers. The manager said that the organised activities were limited mainly because of lack of ability of residents to maintain concentration but that 1:1 activities regularly took place. Several of the returned comment cards expressed a wish for the home to provide more activities and one card stated “we do not have activities at the moment”. There were two dining areas, one for residents requiring more support and the other for more independent residents. The owner said many residents required encouragement to eat – without this some would ‘forget to eat’. Staff were observed in providing appropriate and sensitive intervention and support to those residents who required additional help. Chef outlined meal times, which appeared to be flexible. She talks to residents regularly about their likes and dislikes and the home had a four-week menu, which appeared to provide a balanced and healthy diet, and snacks were available at all times. Fresh fruit was always available and the chef said a trolley was left every evening with a variety of food for example bread, fruit and homemade cakes and scones. The menu was on display on the notice board in the entrance so residents and relatives could see what was available. All residents appeared to be well fed and well nourished. A tour of the kitchen was made. The kitchen was found to be clean and well organised. Adequate supplies of food were seen which included fresh fruit and vegetables. All food was seen to be stored appropriately. Marion Lauder House DS0000061036.V316809.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home encouraged and supported people to raise their concerns and complaints and had the policies, procedures and systems in place to protect residents from abuse. EVIDENCE: The home had a complaint procedure, which was on display in the main reception area. The acting manager said that relatives/visitors and visiting professionals to the home are encouraged to raise concern or complaints. In addition the owner of the home was available on site two or three days per week and regularly talks to residents and relatives and if they have any concerns he addresses them straightaway. He gave examples of issues about laundry facilities and how the home had improved facilities through appointing a laundry person. This had been identified in the 6 monthly quality questionnaires and actions taken fed back to relatives in a six monthly newsletter. Since the last inspection, the home had received one complaint. Evidence was seen that the complaint had been immediately acknowledged by the home and a thorough investigation had taken place. The complainant had taken the complaint to Social Services and it was currently under Protection of Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 15 Vulnerable Adult (POVA) investigation. However following this inspection visit the Commission was informed, by Social Services, that the complaint had been investigated and had not been upheld. Evidence was seen that staff had attended POVA training. The home had policies relating to the Protection of Vulnerable Adults from Abuse and had a copy of the Manchester Multi-Agency Policy on the Protection of Vulnerable Adults from Abuse “No Secrets” guidance. Marion Lauder House DS0000061036.V316809.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean comfortable, well maintained environment was provided for residents. EVIDENCE: The home provides accommodation on 2 levels. There is a secure front door and the large entrance area has comfortable sofas for residents and visitors. There is a notice board with details of home for example a list of residents/relative meeting for all of 2007, menus, CSCI details, hairdressing details including prices. The home was being maintained to a good standard and the overall appearance of home was clean, comfortable and free from odours, which was also confirmed in the returned comment cards. Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 17 Residents had free access to all communal areas of the home. It was encouraging that signs were in corridors indicating which bedrooms were in that section. A private, safe, secure garden area was available to residents, which includes a grassed area and an attractive landscaped garden, which was freely accessible from patio doors off one of the lounges. The home provides ample communal areas, which include 2 dining areas and 3 lounge areas. Accommodation is provided in single bedrooms, with the exception of one double bedroom, which two ladies have shared for many years. Privacy was being maintained by a dividing curtain / screen. The owner has plans in place to build an extension, and this will increase the number of en suite facilities. The home provided ample toilet and bathroom facilities. Toilets were conveniently located in close proximity to bedrooms and communal areas. A variety of bathing facilities were provided to meet a range of needs. There was evidence of ongoing decoration and maintenance throughout the home. Marion Lauder House DS0000061036.V316809.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff available appeared sufficient to meet the residents assessed needs and the home’s recruitment and selection policies ensured they employed staff with the appropriate experience. A training programme ensured staff had the skills to meet the needs of residents. EVIDENCE: At the time of this visit the home accommodated 45 residents. The numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of residents accommodated. The owner is on site 2 or 3 days per week and the home has recently employed the service of a Registered Mental Nurse (RMN) to take responsibility for staff supervision and further development of the service provided at the home. The home had an annual training plan, which reflected key objectives in the home’s business plan. The home had documentary evidence of courses attended by all staff, over a wide range of courses. All files seen had a summary of training attended, which was up to date, and had certificates of courses attended. Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 19 The home use Cheadle & Marple College for NVQ training and are part of a consortium with South Trafford for Health & Safety training and a variety of other courses. The home has in-house Moving and Handling training, Moberley Care have provided ‘training the trainer’ course and internal trainers attend an annual update. One nurse was undertaking Palliative Care course and they are then responsible for cascading the information to colleagues. The home had purchased a POVA training course and have recently purchased a new Induction package they are introducing with new staff. On day of the visit a training session on Dementia Care organised for the afternoon. A random selection of 8 staff files were seen. They were well organised and contained all the relevant documentation. Supervision records were kept in a separate single file, in alphabetical order. Two of the staff files seen did not have supervision notes, as they were new members of staff. The home was in the process of redeveloping the supervision system and there was evidence of work in progress. Staff spoken to confirmed they had received supervision sessions. One relative, via the comment cards, had commented that “communication can sometimes be difficult due to English not being the first language of staff providing care.” This was discussed at length with the owner who tries to ensure staff have good communication skills without being discriminatory. He stated that he would seek further advice on the matter. Marion Lauder House DS0000061036.V316809.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, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates in the best interests of the residents. EVIDENCE: The homeowner and the acting manager were available throughout the inspection visit and clearly had a thorough knowledge of all aspects of the home. A newly appointed manager was expected to take up post in April 2007. It was commendable that the home had achieved Investors in People within first year of ownership. Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 21 The home had a quality audit system whereby it carries out surveys through questionnaires with both relatives and residents, every 6 months. The most recent one was still being processed. Some of the returned questionnaires were seen and had positive with comments like ‘I think my family and me rate the home as brilliant, lovely staff, always very helpful and so friendly’ and ‘I am confident that my mother is in a safe place and frequently happy in her own world around her”. Information from the questionnaires was summarised and put into newsletter, which was sent to all relatives twice a year. The newsletter provided an update on developments in the home and a summary of feedback from previous questionnaires. The homeowner said he frequently speaks to other health care professionals involved with the service and gets more informal feedback about the service. The home had appropriate procedures in place for the handling and management of residents personal monies. Evidence was provided that the home had appropriate service contracts in place for equipment and installations used in the home and that servicing was undertaken at the required intervals to ensure the safely of residents. Marion Lauder House DS0000061036.V316809.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 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 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 4 17 x 18 3 3 x x x x x X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement 1. The GP’s instructions must be recorded to ensure that medication is given as intended. 2. Medication with a limited life must clearly document the date of opening to ensure out of date medications are not given to residents. Timescale for action 19/03/07 Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 24 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 OP7 OP9 Good Practice Recommendations It is recommended that the risk assessment relating to bed rails be reviewed and further developed to adequately assess the actual use of the bed rail. 1. It is recommended that the MAR should clearly cross reference to where there is a signed accurate recording of thickened fluids given to residents. 2. It is recommended that 2 staff witness and sign for the disposal of waste medication. 3. OP12 3. In order to facilitate a full audit trail of medication it is recommended that medication carried over form the previous month is recorded on the MAR. It is recommended that residents/relatives are consulted about their social interests/hobbies. These should then be recorded to ensue that any activities provided suite the individual preferences of residents. Marion Lauder House DS0000061036.V316809.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Marion Lauder House DS0000061036.V316809.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. 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