Inspection on 25/04/06 for Pensall House Resource Centre

This inspection was carried out on 25th April 2006.

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

Other inspections for this house

Pensall House Resource Centre 17/10/07

Pensall House Resource Centre 15/11/05

Pensall House Resource Centre 21/04/05

Pensall House Resource Centre 08/12/04

Pensall House Resource Centre 26/08/04

Pensall House Resource Centre 09/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Pensall House Resource Centre Fairview Way Pensby Wirral CH61 6XL Lead Inspector Inger Moynihan Key Unannounced Inspection 25th April 2006 11:00 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 Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 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. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pensall House Resource Centre Address Fairview Way Pensby Wirral CH61 6XL 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) 0151 666 4648 Metropolitan Borough of Wirral Mrs Susan Teresa White Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two (2) beds to accommodate persons under 65 years of age in an overall total of 25 15th November 2005 Date of last inspection Brief Description of the Service: Pensall House is a two storey, purpose built unit owned and operated by the Metropolitan Borough of Wirral. It is easily accessible to the local facilities and amenities of Pensby and Heswall. Bus routes are close by. The unit is located in a residential part of the Wirral. There are good parking facilities at the front of the unit and wheelchair access is available at the front entrance. Bedrooms are located on two floors with a lift being provided to access these rooms. All rooms are single occupancy with ensuite facilities comprising of a toilet and wash basin. There is sufficient communal space for the number of service users accommodated at the unit which includes a large dining room and a number of lounges. A separate smoking room is provided. Pensall House is furnished and decorated to high standard which provides a homely and comfortable environment for the service users. A range of equipment is provided to assist service users with their bathing and mobility. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five hours and was the statutory unannounced inspection for 2006/2007. Discussions were held with the service users about their experience of living at Pensall House; the views of their family were also obtained. Discussions were held with the registered manager and the staff team about the management and daily working practices of the unit. Service users case files and supporting documentation was examined and a tour of the unit took place. A part of the inspection process includes sending questionnaires out to service users and their relatives or carers in order to obtain their views about the standard of care provided at Pensall House. Comments made in these questionnaires are included in the report and contribute to the basis of any judgments made. What the service does well: Service users are only admitted into the home on the basis of a full assessment which ensures staff can provide the appropriate package of care. Service users health, personal and social care needs are set out in an individual plan of care. Issues of equality and diversity are addressed throughout which ensures staff have the necessary information to meet service users individual care needs. Pensall House provides an intermediate care service to help service users to maximise their independence and return to their own home. Efficient systems are in place to ensure service users good health. Service users feel they are treated with respect and their right to privacy is upheld. A range of social activities is provided to promote service users interests and to provide mental stimulation. Service users can maintain contact with their family and friends at any time. The routines in the unit are flexible which ensures service users can exercise choice and control in all aspects of their lives. A varied and nutritious diet is provided to ensure service users good health. Service users are confident their complaints will be listened to, taken seriously and acted upon. Systems are in place to ensure service users are protected from abuse. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 6 The standard of the decor throughout the unit remains very high and provides a comfortable and pleasant environment. Service users needs are met by the number and skill mix of staff who have completed appropriate training. The unit has thorough recruitment procedures to ensure suitably qualified and competent staff are employed. The registered manager is qualified, competent and experienced to manage the unit which is run for service users best interests. She does not handle service users money on a daily basis. The health, safety and welfare of the service users are promoted throughout the unit. 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. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 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 Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The quality in this outcome area is good. Service users are only admitted into the home on the basis of a full assessment with issues of equality and diversity being addressed. This ensures staff have the necessary information to meet service users individual care needs. Pensall House provides a good intermediate care service to help service users to maximise their independence and return to their own home. EVIDENCE: Examination of documentation relating to the assessment process indicated that a range of appropriate issues had been assessed to ensure the staff know how to look after the service users properly. The assessments documentation addresses issues of equality and diversity such as race, religion, age, gender, sexuality and disability. This ensures staff have the information they need to look after the service users properly and in accordance with their specific care requirements. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 9 Service users spoken to during the inspection confirmed their needs were fully met and they praised the staff team for their kind and caring nature. Intermediate care is provided at Pensall House to help service users to maximise their independence and return to their own home. This service is provided as a part of the overall service of respite care but has the additional support of a team of health care professionals. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality in this outcome area is good. Service users health, personal and social care needs are set out in an individual plan of care with issues of equality and diversity being addressed. This ensures staff have the necessary information to meet service users individual care needs. Efficient systems are in place to ensure service users good health. Improvements need to be made to the medication administration procedures to ensure service users medication is correctly accounted for and administered according to direction. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: A documented plan of the care provided to each service user is in place and provides staff with the information they need on how to meet service users needs. The care plan covers a range of relevant issues and documentation is Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 11 in place to indicate this information had been reviewed with appropriate changes being made. Not all of the information highlighted in the care plan had been specifically addressed in the review, although there was recorded evidence that specific issues had been monitored by a relevant health care professional. To ensure the care plans are an accurate reflection of service users care needs and to demonstrate the decision-making behind any changes made, the registered person is required to ensure all parts of the care plan are reviewed with a record being kept of the information collated. The issue of equality and diversity is addressed in the care planning process. This ensures staff have the information they need to care for the service users in accordance with their specific care requirements. The service users spoken to during the inspection confirmed they had access to relevant health care professionals when necessary and said they felt well cared for. Service users family were also spoken to during the inspection, they too felt their relatives received a high standard of care with one person is saying the staff are all excellent and very attentive to my mothers care needs. Documentation is in place to demonstrate service users have access to a range of appropriate health care professionals and that their ongoing health care needs are monitored daily. Questionnaires returned to the CSCI from service users indicated they were happy with the standard of care they received with one person recording I have been very satisfied with the time I have spent at Pensall House. Efficient systems are in place for the safekeeping and handling of service users’ medication and only trained staff are allowed to administer medication. A policy and procedure in relation to the administration, safe handling and recording of medication is available for staff reference; staff confirmed they have access to this information. All of the service users spoken to during the inspection confirmed they received their medication as prescribed by their GP. Examination of the documentation indicated that in two instances the information held in the records did not accurately reflect the amount of medication held. This issue was discussed with the registered manager and a senior member of staff who agreed to look into the matter straight away. Although handwritten entries had been made on some medication administration record sheets, only one staff signature had been recorded to confirm the accuracy of the information held. For the purposes of service user safety and welfare, the registered person is required to ensure two staff signatures are obtained on hand written medication administration record sheets. The service users spoken to during the inspection confirmed the staff treated them with respect and dignity at all times saying the staff are always polite Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 12 and friendly. They confirmed they could see their GP in private and could maintain contact with relatives and friends. The inspector observed the staff interacting with the service users during inspection and they were always polite and courteous. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality in this outcome area is excellent. A range of social activities are provided to support service users interests to provide mental stimulation. Service users can maintain contact with their family and friends at any time. The routines in the home are flexible which ensures service users can exercise choice and control in all aspects of their lives. A varied and nutritious diet is provided that ensures service users good health is promoted. EVIDENCE: The service users confirmed a range of activities are provided within the home which they could participate in if they wish. Some of the service users stated they did not wish to become involved in these activities and were happy the staff respected their decision. The service users spoke about a recent occasion the staff had organised to celebrate the Queens Birthday. They said the staff had made a great deal of effort to make this an enjoyable time for everyone concerned and they all thoroughly enjoyed the day. This was further Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 14 reinforced by a relative of one of the service users who praised the staff for making this day into a special occasion. The service users confirmed the routines in the unit flexible which meant their family and friends could visit at any time. All of the bedrooms are single occupancy which means service users can meet with their family in private; a couple of small lounges are also available for this purpose. Service users manage their own finances or are supported by their family. The registered manager and staff team do not handle service users money. A varied and balanced diet is provided and service users medical requirements are met. All of the service users spoken to during the inspection confirmed they enjoyed the meals and confirmed an alternative meal was always provided. One service user commented the food is beautiful and I always have plenty to eat and drink. Service users medical needs are included in the menu planning. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is excellent. Service users are confident their complaints will be listened to, taken seriously and acted upon. Systems are in place to ensure service users are protected from abuse. EVIDENCE: The complaints procedure is clearly displayed in the home and the staff spoken to during the inspection are aware of the action they should take in the event of them receiving a complaint. None of the service users spoken to during the inspection had any complaints to make about the standards of care provided at Pensall House and were confident their concerns would be listened to and acted upon appropriately. They all praised the registered manager and the staff team for their kind and caring manner. One service user commented the staff are lovely, they really couldnt do better. The care is excellent. The relatives of a number of service users were also spoken to during inspection. They confirmed they had no complaints to make and again praised the manager and staff team for the high standard of care their relatives received. One relative stated I am delighted with the care my mother receives and the staff could not be kinder, I really couldnt praise them highly enough. All staff have completed training in relation to the protection of vulnerable adults from abuse and further training in relation to this aspect of care provision has been planned for the future. The service users spoken to during inspection confirmed the staff are always kind and friendly and they had never Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 16 been spoken to or treated badly in any way. A policy and procedure in relation to the investigation of any issues of abuse was in place along with a copy of the Wirral adult protection procedures. All of this ensures any allegations of abuse are investigated and dealt with properly. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 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 and 26 The quality in this outcome area is excellent. The standard of the decor throughout the unit remains very high and provides a comfortable and pleasant environment for service users to stay. EVIDENCE: The standard of furnishings throughout the unit remains very high and the grounds are well kept. A programme of routine maintenance is in place to ensure the unit is well maintained and provides a comfortable and pleasant environment to stay. The standard of hygiene remains very high and there are sufficient laundry facilities to cater for the number of service users staying at the unit. Systems are in place to control the spread of infection along with supporting policies and procedures which staff can refer to when necessary. Staff spoken to Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 18 confirmed they had also completed training in relation to hygiene and infection control which means they know how to ensure service users welfare and safety. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 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 and 30 The quality in this outcome area is good. Service users needs are met by the number and skill mix of staff. Staff have completed appropriate training to ensure the service users are cared for properly. Training in relation to equality and diversity needs to be provided to ensure service users specific care requirements are being met. The home has thorough recruitment procedures to ensure suitably qualified and competent staff are employed at the home. EVIDENCE: This staff rota submitted prior to the inspection indicated there are sufficient care and domestic staff on duty to ensure the service users are kept safe and are well cared for. Discussion with the staff confirmed they had sufficient time to carry out their work with the amount of staff on duty at any one time. Service users spoken to during the inspection said the staff are always available for assistance when needed. Documentation submitted by the registered manager prior to the inspection indicated that nine of the 19 care staff employed at the unit have completed NVQ 2 or above. This is a positive aspect of the home and ensures the staff are up to date with current good practice and that the service users receive the care they need. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 20 Thorough recruitment procedures are carried out. Documentation examined indicated that appropriate checks had been carried out on all staff. Staff spoken to confirmed they had completed a Criminal Records Bureau check. All of this contributes to ensuring that suitably qualified and competent staff are employed to work at the unit and that they are suitable to work with vulnerable adults. Documentation submitted by the registered manager prior to the inspection indicated that staff are provided with ongoing training and that further training is planned for the forthcoming year. The Wirral Social Services continues to have a positive approach towards staff training which ensures the service users are cared for appropriately and staff are kept up-to-date with current good practice. The staff spoken to during inspection said they enjoyed their work and felt well supported in their role. They confirmed they had undertaken a range of appropriate training which they enjoyed. They said the staff worked well as a team and there were sufficient staff on duty to carry out their work and care for the service users appropriately. The issue of equality and diversity was discussed with the registered manager. She explained that the Wirral Social Services is in the process of addressing this issue initially by assessing staffs understanding of issues around race, religion, age, gender, sexuality, and disability. A programme of training will then be provided to all staff to ensure they have an understanding of this sometimes complex issue. It is anticipated that this training will be provided for staff within the forthcoming year. Through discussion the registered manager stated that prior to this training being provided, she would discuss this issue in more detail with the staff team during supervision and team meetings. By doing this she could carry out her own audit of staffs understanding of this issue and their particular training needs. A policy around equality and diversity is in place which staff can access at any time. Service users spoken to during inspection praised the staff team for their kind and caring nature stating their care needs were fully met. One service user stated the staff are marvellous, I have everything I need and I really feel as though Im getting back on my feet after not being well for some time. Questionnaires returned to the CSCI from service users indicated they were happy with the standard of care they received with one person recording I have found all of the staff very helpful and kind. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 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, 33, 35 and 38 The quality in this outcome area is excellent. The registered manager is qualified, competent and experienced to manage the unit, which is run for service users best interests. The health, safety and welfare of the service users are promoted throughout the home. EVIDENCE: There are clear lines of management and accountability within the home which is run for service users best interest. Mrs Susan White is qualified to NVQ level 4 which is the recognised qualification for a manager of a residential care service. All of the service users spoken to during the inspection said Mrs White was always available for support and advice when necessary. The relative of one service user said the manager is wonderful and runs a very good unit. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 22 The GP who holds a surgery at the unit each week stated Mrs White is always up-to-date with regard to the care issues in relation to his patients. The registered manager demonstrated she was aware of her responsibilities with regard to the management of the unit, supervision of staff and the care of service users. This information demonstrates the unit is run for service users best interest. Systems are in place to ensure the high standards of care provided at Pensall House. This the includes the Responsible Individual carrying out regular visits to the home to ensure high standards of care are being maintained and the unit implementing a business plan to establish how further improvements can be made to the service provision. The manager will monitor specific aspects of care provision and will carry out spot checks around the building. The senior staff work closely with the service users and report to the registered manager on their welfare and well-being. Staff meet regularly with a senior member of the staff to discuss their care practices or any issues of concern they may have in relation to the welfare of the service users. All of this contributes to ensuring the care provided at Pensall House is maintained to a high standard and that the service users are looked after properly. At the last inspection a discussion was held about the way the units amenity fund was managed. Since this time a more improved system has been set up although more detailed records still need to be kept to ensure the information can be audited more easily. The registered manager agreed to ensure this issue was addressed within two weeks of the inspection. Service users take responsibility for the management of their own finances and the weekly fees are dealt with through the Social Services finance department. The health, safety and welfare of the service users and staff are promoted throughout the home. Staff confirmed they have completed training in this aspect of care provision and have access to policies and procedures to support them within their role. Documentation examined indicated that regular safety checks are made on all equipment used in the home. Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 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 x x 3 x x 3 HEALTH AND PERSONAL3 CARE Standard No Score 7 3 8 4 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 4 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 4 x 3 x 2 x x 4 Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 24 yes 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 OP9 Regulation 17 Requirement Timescale for action 09/05/06 2 OP9 17 3 OP28 12 and 18 4 OP3535 17 The registered person is required to ensure the records held in relation to the amount of medication stored are accurately maintained. The registered person is required 09/06/06 to ensure two staff signatures are obtained on any medication administration record sheet where handwritten entries are made. The registered person is required 01/05/07 to ensure all staff are provided with training on issues of diversity. The registered person is required 09/05/06 to ensure more detailed records are kept to demonstrate how the money from the Pensall House amenity fund is spent. An auditing system must also be introduced. (The timescale for this requirement was 31/03/05) Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Liverpool Local Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Pensall House Resource Centre DS0000035958.V287539.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!