Inspection on 12/10/06 for Oak Tree Mews

This inspection was carried out on 12th October 2006.

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

The inspector 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

Oak Tree Mews 09/02/06

Oak Tree Mews 12/09/05

Oak Tree Mews 10/01/05

Oak Tree Mews 13/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Oak Tree Mews Hospital Road Moreton-in-marsh Glos GL56 0BL Lead Inspector Sharon Hayward-Wright Key Unannounced Inspection 08:00 12th October 2006 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 Oak Tree Mews DS0000016517.V310538.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. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oak Tree Mews Address Hospital Road Moreton-in-marsh Glos GL56 0BL 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) 01608 650797 01608 652735 www.schealthcare.co.uk Southern Cross Healthcare Services Limited Ms Rashida Ilyas Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Oak Tree Mews is a modern Cotswold stone family home, which has been extended and converted into a care home. It is located in a quiet no- through- road in close proximity to the High Street in the market town of Moreton-in-Marsh. The local hospital is within walking distance. The accommodation is on two floors, the ground floor having a number of bedrooms and the communal areas, which consist of a lounge/dining room and conservatory. On the first floor are the remaining bedrooms and a shaft lift providing access to this floor. Fifteen bedrooms have en-suite facilities. The remaining two have toilets adjacent. Eighteen bedrooms are for single occupancy, while the remaining room, although registered as a double, is used by one service user. There is easy access from the home to the large, welltended gardens, which have a number of parking spaces in front of the building. To the rear of the property there are open views to the countryside. The fees for this home start at £550 per week. Additional services not included in the fees include hairdressing, chiropody and newspapers. This information was given to the inspector prior to the inspection. Copies of the homes Statement of Purpose and Service Users Guide are displayed in the main entrance to the home. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection on one day in October 2006. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes in to account the views and experiences of people using the service. The Registered Manager was available during the inspection as were other members of the home team. A total of 26 standards were inspected. Several residents were spoken with to ascertain their views on the care and services provided. A number of surveys were left for service users, staff and visitors to the home. Of these, seven service users returned theirs. The majority of comments received relate to food and these are discussed further in the report. The comments received from service users during the inspection all indicated they are very happy living at the home. A relative and visitor to the home all praised the staff and Registered Manager saying they are very happy with the service provided by the home. The Registered Manager and care staff were spoken with throughout the inspection and were helpful and co-operative. Feed back on the inspection findings were given on completion of the site visit and were received in a constructive and positive way by the Registered Manager. Following the inspection an urgent action letter was sent to the home to address the serious issues identified with controlled medication during the inspection. Southern Cross have responded to this letter with an action plan on how they have addressed these. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home now has a varied activities programme for service users and during the inspection a number of service users were enjoying a quiz, exercises and PAT dog. The home has improved their care planning systems to ensure all the required information is available for staff, however this could be further improved by ensuring staff date care documents on completion and risk assessments are not left blank. Storage facilities have been improved in the home so that equipment is no longer stored in bathrooms. A small number of maintenance issues identified at the last inspection have been addressed. Since the last inspection the Manager has been registered with the Commission. The home has provided a number of training courses for staff to ensure they are provided with the skills and knowledge to care for the service users. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 7 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. Oak Tree Mews DS0000016517.V310538.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 Oak Tree Mews DS0000016517.V310538.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. The homes Statement of Purpose and Service Users Guide are excellent providing service users and prospective service users with details of the services the home provides enabling an informed decision about moving into the home. Arrangements are in place to ensure service users are not admitted to the home without first having their needs assessed and assurance that the home can meet their needs. EVIDENCE: The homes Statement of Purpose and Service Users Guide contain details of the information about the services offered by the home. These guides are offered in other formats. Copies of these are available in the main entrance along with a copy of their last inspection report. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 10 The main entrance also has several notice boards containing a variety of information that might be relevant to service users and their visitors, and displays photographs of outings and the homes summer fete. The Registered Manager said all new service users receive a copy of the service users guide on admission to the home, however two service users asked could not remember. It was noted in the Service Users Guide that it contained abstracts from inspections reports. All inspection reports are subject to copyright laws and prior permission must be obtained from the CSCI. The home must find out if this permission has been obtained. Contracts were not examined in detail at this inspection but copies were seen in both service users files. Pre admission assessments of two recently admitted service users were examined. One was undertaken by another home Manager as the service user was from out of the area. Both contained details of each service users needs and one had pre admission care plans devised. A copy of the letter sent to one service user confirming the home can meet their needs was seen. One service user confirmed they had visited the home prior to moving in. Intermediate care is not offered at this home. Oak Tree Mews DS0000016517.V310538.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a site visit to this service. The home has a clear and consistent care planning system in place that on the whole provides staff with adequate information they need to satisfactorily meet service users needs. Health professionals are accessed for service users with an assessed need. Poor practices within the medication systems used potentially place service users at risk. EVIDENCE: The care of two service users was examined in detail and another service user’s care plans were seen as evidence of multi disciplinary working. Both service users had been admitted to the home within the last couple of months and their needs assessment was up to date. The home will need to ensure the assessment of needs for all service users is kept up to date. All service users had care plans in place and evidence was seen of reviews in one of the care plans and six monthly reviews with the Registered Manager, key worker Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 12 and service user were also seen. One service user had two care plans that were not dated when they were devised and tippex had been used. This service user had signed their care plans. Daily records are maintained for each service user. All service users had risk assessments in place for pressure sores, continence, bowels, nutrition, moving and handling, falls and dependency. However one service user admitted in the middle of September did not have two risk assessments completed. Written risk assessments were in place for service users where necessary. Evidence was seen of health professionals’ involvement with service users. One service user receives a lot of input from health professionals’ and evidence was seen of this in their care plans. A local GP was visiting the home during the inspection. Medication systems were examined. Both new service users had a list of their medications listed on their pre admission records. Each service user has a front sheet with their name, room number, allergies and photograph. Records were seen for medication received, administered and returned to the pharmacy. However records were not maintained of the amount of tablets etc brought into the home by a recently admitted service user. Medication Administration Records (MAR) were examined for each service user. Hand written entries on several MARs’ were not checked and signed by a second person. One service user had a change of dose and again this was not signed by the person altering it or checked and signed by a second person. Written on one MAR was just the name of the medication, no dose or directions for administration. This was a handwritten entry, again not signed by the person writing it and no evidence it was checked by a second person. Gaps were also found in the recordings therefore it would be difficult to establish if the medication had been administered. The home uses a trolley to transport medication around the home and the staff take the Medication Administration Records with them as part of the process of administration. Staff wear a red tabard asking people not to disturb them whilst administering medication. Since the last inspection the home has moved the medication room. Records were seen of the room temperature and medication fridge. Dates of opening were seen on the majority of eye drops and creams. Consideration should be given to the home dating all stock medication on opening to assist with auditing. Not all service users receiving ‘as and when’ medication had the appropriate care plans in place. Several service users were self-medicating part of their medication but no risk assessments or consent forms were seen in their care records. Controlled medication was also examined. The home has purchased a new cupboard for storage and is waiting for it to be delivered. Records and the Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 13 medication were checked, however a discrepancy was found as the amount of medication left was different to the records. Two bottles appeared to be in use and neither bottle was dated on opening so it was difficult to know which bottle was being used. The Registered Manager did not know why there appeared to be more medication than the records suggested. A senior carer was asked if they knew which bottle of medication was being used and they replied that one bottle was medication waiting to be disposed of. As neither bottle was labelled only certain staff were aware which was which. This practice is dangerous and can potentially place service users at risk. An urgent action letter was sent to Southern Cross following the inspection to ensure safe systems were put in place. Records and staff confirmed that they had received training in relation to medication. Service users confirmed staff respect their privacy and dignity. Staff were observed knocking on service users doors prior to entering. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. 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 site visit to this service. The home offers service users the opportunity to participate in a variety of activities to satisfy their needs. Links with the community are good and support and enrich service users social opportunities. Dietary needs of service users are well catered for with a balanced selection of food available but the home needs to improve on the provision of a varied menu to suit the choices of service users. EVIDENCE: Since the last inspection the home has improved their activities programme for service users. A list of activities is displayed on the notice board outside the dining/lounge room. Activities planned for the day of the inspection included exercises, PAT dog and a quiz. A large number of service users attended the quiz in the afternoon. Photographs are displayed in the main entrance hall of the homes’ summer fete and a recent coffee morning. A poster was also advertising a coffee morning planned for the next few weeks. One service user was going out with their family during the inspection and several other service Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 15 users were walking around the grounds. Service users confirmed they have the choice about whether they take part in the activities as some service users said they like to make their own activities. The home has plans in place to arrange a trip out at Christmas time for service users to see the lights. Links with the community are maintained, as service users are able to go to the local town if they are able. The home has strong links with the local GPs’ community nurses and community hospital. Several visitors were at the home during the day of the inspection. The notice board in the main entrance to the home displays information about advocacy services and where to contact them. Evidence was seen that two service users are subject to Power of Attorney process. A number of service users rooms were inspected and found to be very personalised. Service users confirmed that they are able to make decisions about their daily lives. A menu is displayed in the dining room for service users and they confirmed that choices are offered. Food records also confirmed this. The home has had a recent Environmental Health visit and the report was seen. The Registered Manager confirmed that the requirement has been addressed. Health and safety checks are undertaken in the kitchen and records were seen of these. Lunchtime was observed and found to be a very social event. Service users confirmed that they could choose where they have their meals. Drinks were seen being offered to service users throughout the day. The home as part of their quality assurance system have undertaken an audit of food and from this an action plan will be put in place. Service users spoken to as part of the inspection said they enjoyed the food provided, however surveys received from service users following the inspection highlighted that there was not enough variety and the food was repetitive. One said they felt the quality has improved. The Registered Manager is aware of these comments, as they have been fed back to her following their food audit. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 16 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 inspected at least once during a 12 month period. 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 site visit to this service. The complaints process in this home is good with complaints information available to service users and evidence that their views are listened to and acted upon. The home has arrangements in place for protecting service users from possible risk of abuse or harm. EVIDENCE: The home has a complaints procedure as required under the Care Home Regulations and copies of this are available in the home. Service users spoken with at the inspection and from the surveys received after the inspection all said they would speak with the Registered Manager if they had any concerns. Records were seen of complaints received, investigations and their responses. The home has provided staff with an update on adult protection issues and further training is planned for November to ensure all staff receive this training. Staff confirmed they have received training. The home has a copy of the Alerters guide on their notice board in the main entrance. The homes policies and procedures include whistle blowing and abuse. Oak Tree Mews DS0000016517.V310538.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. The standard of the environment on the whole is good and with the planned redecoration this will enhance the environment further for service users. EVIDENCE: A tour of the home took place with a number of service users rooms seen. All the maintenance issues identified at the last inspection have been addressed. The home has replaced the flooring in the dining room and carpets in the communal areas. One service users room had a slight odour but the home is aware of it and is working hard to combat it. In places the decoration is looking ‘tired’ and in the bathroom on the ground floor the wallpaper is peeling off the wall. The Registered Manager said that they have plans to redecorate areas and when rooms become available they are redecorated prior to a new service user moving in. The outside window frames at the back of the home have parts where the paint is peeling. The fire escape route from Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 18 upstairs down to the rear garden also has damage to the wall. Again the Registered Manager is aware and it is in hand to be repaired. The laundry room was seen and the home has one washing machine and dryer. The washing machine has the appropriate programmes. The transportation of laundry was discussed and the home has suitable bags in place. Staff were seen wearing protective clothing as necessary. Service users spoken with all said they were happy with the cleanliness of the home. Oak Tree Mews DS0000016517.V310538.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 at least once during a 12 month period. 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 site visit to this service. The home is confident that the numbers of staff on duty meet the needs of the service users, and the home has processes in place to ensure staff receive training for the tasks they are to perform. Safe recruitment practices are taking place but the home needs to be more vigilant with the timings of these checks to ensure service users are not put at risk. EVIDENCE: Since the last inspection the home has increased their afternoon staff from two to three to ensure the needs of their service users are met otherwise no changes have been made to the staffing levels. Off duty records were seen. The home has not used any agency staff recently. Service users spoken with all said the staff are very helpful and friendly. Staff said they enjoy working at the home. Six care staff have NVQ 2 and three have just started this training. One member of staff has NVQ 3. The home also has two other staff with equivalent qualifications to the NVQ training. The personnel files of two recently appointed members of staff were seen. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 20 One required a photograph and this was done during the inspection. Gaps in the employment history of other member of staff were found; again this was rectified during the inspection. The home needs to be mindful that these checks must be completed prior to the member of staff starting work at the home. Otherwise evidence of the checks required by the Care Home Regulations was seen in the home. A training matrix was seen in the home, which identifies when training is due. Plans and dates for training were seen to ensure staff are kept up to date. An induction book was seen of a new member of staff. Southern Cross uses a set format and included on this booklet is the name of the staff member’s supervisor. Oak Tree Mews DS0000016517.V310538.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35,36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. The Registered Manager has a supportive, open approach to running the home, which benefits the service users, staff and relatives. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of, service users and visitors to the home. Systems are in place to ensure service users monies are safeguarded. The home ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 22 EVIDENCE: Since the last inspection the Manager has been registered with the Commission. She has nearly completed the Registered Managers award. The Registered Manager also undertakes staff training and she has courses booked to keep herself updated. Staff and service users feel the Registered Manager is approachable and friendly and will listen to their concerns. Quality assurance systems were examined. The home undertakes monthly audits and on alternate months the Operations Manager completes one of these audits. Recent food surveys have been sent out to service users by the home and they are still receiving replies and then they will devise an action plan to address any issues. Satisfaction surveys are sent out on a continuous basis and a response was seen from a GP. Minutes were seen of service users meetings and these are also displayed in the main entrance to the home. Monthly audits are undertaken on pressure sores, accidents, medication, complaints, recruitment, care plans and the kitchen. The home manages money for a small number of service users. The appropriate records and receipts are maintained and kept by the home. The Registered Manager has a plan in place to supervise staff. Senior Carer staff supervise carers. Appraisals are in the process of being completed. Records were seen of supervision sessions. Minutes were also seen of staff meetings. Records were seen of servicing of equipment and monthly checks. The home has a fire risk assessment in place. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 23 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 4 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 3 X 3 Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 24 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 Timescale for action 20/10/06 2. OP9 13(2) & 15 3. OP9 13(2) The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. (This relates to the safe keeping, recording and safe disposal of controlled medication.) An urgent action letter was sent to the home following the inspection for this to be addressed as a matter of urgency. The Registered Person shall 30/11/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. (This relates to care plans needed for medication and risk assessment and consent forms for service users wishing to selfmedicate.) The Registered Person shall 20/10/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the DS0000016517.V310538.R01.S.doc Version 5.2 Oak Tree Mews Page 25 home. (This relates to the recording of medication on the Medication Administration Record.) 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 OP1 OP7 OP7 Good Practice Recommendations The home should ensure that permission has been obtained from the CSCI before taking abstracts from inspection report. The home should ensure that all staff sign and date any assessments that are completed by them. The home should ensure that staff fully completes all assessments on service users within the five days of admission to the home. Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 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 Oak Tree Mews DS0000016517.V310538.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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