Inspection on 26/07/05 for Primrose House (Morecambe) Ltd

This inspection was carried out on 26th July 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Primrose House (Morecambe) Ltd 12/12/06

Primrose House (Morecambe) Ltd 19/01/06

Primrose House (Morecambe) Ltd 08/03/05

Primrose House (Morecambe) Ltd 01/06/04

Primrose House (Morecambe) Ltd 10/03/04

Primrose House (Morecambe) Ltd 28/10/02

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Primrose House (Morecambe) Ltd Primrose House Middleton Road, Middleton Morecambe, Lancashire LA3 3JJ Lead Inspector Joy Howson-Booth Announced 26 July 2005 10:00am th 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Primrose House (Morecambe) Ltd Address Primrose House, Middleton Road, Middleton, Morecambe, Lancashire. LA3 3JJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01524 853385 Primrose House (Morecambe) Limited Mr Anthony David Grundy CRH Care Home 6 Category(ies) of LD Learning Disability 6 registration, with number of places Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 2005 Brief Description of the Service: Primrose House (Morecambe) Limited is a home for up to 6 people with severe learning and physical disabilities, the present (purpose-built) building opened in 1998 but the Primrose House service has been in operation since 1988. The service was established as a charitable organisation by one of the parents of a current service user who found that there was no satisfactory service provision existing locally to meet complex needs. A Board of Trustees appointed a Registered Manager to undertake the day-to-day management of the home. A responsible person has also been appointed to monitor the service. The Board of Trustees meets on a regular basis to review the service and plan future developments. The ethos of the home is to “provide quality services to people who have a profound learning and physical disability and it believes that opportunities should be provided to enable the people supported to live independent lives within the confines of their disability”. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day and was announced. As well as talking with one of the residents, staff, a parent and the registered manager were also spoken with. It was useful to talk with the new designated “responsible person” for the Board of Trustees, as well as other Board members. As well as examining care plans and other paperwork for three residents, medication records and staff files were also examined. Prior to this inspection taking place, the registered manager sent in additional information about the home which has also been used within this report. What the service does well: The service provides an individualised and person-centred way of giving care to the residents who live at this home. The home was built especially to meet the needs of people who have both physical and learning difficulties. The six residents have all been at the home for a number of years and have built up relationships with each other and members of staff. Each resident has their own timetable for care and activities which uses the information provided by relatives and from experience to plan and provide an excellent quality of life. Comment cards were received from one parent which stated they were made welcome, were kept informed of important matters, and were satisfied with the care provided. Comment cards were also received from a number of professionals and their comments included “all the carers know residents well, anticipating their needs and providing excellent care in all areas”. “I have always had good co-operation from all staff when making recommendations for clients care plans.” “I felt when I visited the staff at the home they were very forward thinking and inclusive of the relatives, service users and myself.” “The home communicates clearly and works in partnership – staff demonstrate a clear understanding of the care needs of the service users – any specialist advice I give is incorporated into the care plan.” The home is maintained to a high standard, with an ongoing redecoration programme in place. Equipment and other building checks (e.g. wiring, central heating) are all carried out on a regular basis by people who are qualified to do so. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 6 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. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 5 There are very good arrangements in place to make sure the needs of any prospective resident would be assessed so that all parties know identified needs will be met. The terms and conditions provide clear information over what will be provided. EVIDENCE: There have been no new residents admitted to this home since the last inspection. The home has a comprehensive assessment which would be used, along with an expected care management assessment, to ensure the needs of any prospective resident were fully known prior to making a judgement about moving into the home. Three resident files were seen and found to contain written Terms and Conditions (including a residency agreement) which outlines all the required information. This document has been signed by the respective family member as the residents lack the capacity to do this for themselves. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 There are clear and very comprehensive care documents in place which enable staff to fully know, understand and meet residents needs. EVIDENCE: Three residents files were examined and it was seen that for two the newly implemented Person Centred Planning system has been introduced. This involves the resident (where possible), staff members, relatives and other professionals providing information so that a care plan can be developed from the individual person’s point of view and incorporate aspirations, needs and their preferred lifestyle. For example, what is important to the resident, maintaining contacts with family members, seeing friends and how they want their lifestyle to be. There is also the recognition that the residents, like most people, may like to have time on their own, perhaps listening to preferred music or watching their own television away from other residents and staff. From this information a planning document for care is produced and provides ongoing goals and actions staff need to take to achieve these. Whilst these files contain extremely comprehensive information there is a feeling that some information may potentially be “lost” to the reader. The registered manager was advised to speak to staff regarding these files and whether the layout is user friendly for them. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 10 For the third resident, there is an ongoing action plan of care which details their like, dislikes, care needs, preferences, lifestyles and goals but has not yet been written with person centred approach. The registered manager was advised that all care documentation should be dated and care plans must be reviewed on a monthly basis. There was evidence of Personal Planning meetings which are held on a yearly basis, along with ongoing changes as needed. Discussion with one parent confirmed they are involved in this process and they are very happy with the care provided to their relative. The staff at the home are also developing “personal passports to communication” which detail a range of information and pictures which give staff at the home and a separate passport for use by people in the wider community (for example Tutors at the College). These passports give information over the specific ways that the individual residents communicate their wishes. For one resident this may only be by lifting up one arm or by moving their lips together but are all important and subtle communication methods that may be missed by those not aware. As well as these, residents also have “objects of reference” – for example, an apron which provides a tactile symbol that she is to be taken for something to eat. Another lady has a handbag which signifies that she is going out. Weekly timetables for residents were seen but the registered manager was advised this should be dated as it is unclear how up to date they are as they are not dated. The staff at the home currently maintain an Individual Plan Review Matrix which is ticked when specific activities or events take place. The registered manager was advised that there may be a danger that staff fall into the practice of ticking boxes without reference and he was advised to discuss this form with the staff team to maybe structure it better. Because the residents in this home lack capacity and would not have the ability to take risks independently, this is an area that would be developed at the individual resident’s own pace and as their needs dictated. At present, all activities, outings and social events are required to be intensively staff supported. However, on one care plan it is clearly recorded that the resident wishes to “make my own decisions”. The registered manager was advised that when a decision is taken that involves risk, for example, the use of bed rails for one of the residents, this should be, as much as possible, a multi-taken decision, a risk assessment carried out and reviewed 6 weekly (or sooner if there are concerns). Discussions with one resident confirmed that he is very happy with his current lifestyle and the support he receives from the staff. This resident was aware of his communication passport but was not too positive about using it. Possible Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 11 reasons for this was discussed with the registered manager who is to talk with the key worker to assess. Discussions with staff confirmed they feel the new person centre approach is very good and respects the resident as an individual person. One concern was expressed that if staff have to do everything in a “set way” according to the care plan this may stifle individuality and mean that the resident loses the personal and individual interaction each different member of staff brings. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15 and 16 Residents are supported to have an excellent quality of life which includes experiencing a range of social and leisure and activities which are age appropriate, positive and reflect their preferences and wishes. Residents rights are respected at all times. EVIDENCE: From the care files examined it was clearly evidenced that the staff enable the residents to have very good quality and individual lifestyle. The person centred care plans include opportunities for personal development which include communication skills and maintaining their own individual lifestyles. As mentioned previously, all residents will have their own “passport to communication” which provides information to enable staff and others to learn the individual ways the residents communication and express their wishes. It was noted that the home intends to develop two passports for the residents as there is a recognition that there is some information (e.g. personal care) which the resident “would not like to be shared with everyone”. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 13 The care plans also evidenced that the staff at the home ensure all the residents take part in age appropriate activities. For example, one care plan included – “to choose clothes that reflect my age”, “ to wear colour coordinated clothing that I choose”, “to have my hair in a fashionable style and to have it cut every 6-8 weeks, and coloured or straightened by people trained to do so for special occasions”. The residents are supported to take part in a range of activities, including swimming, attending football matches, attending pop concerts, to go out for walks, have meals out with friends and family, shopping trips, massages, hairdressing, etc. These are carried out in the local and wider community. In addition to this, all the residents enjoyed a holiday – two residents went to Butlins in Skegness, another two residents went to Butlins at a different time, one resident went to Centre Parcs in Longleat and the sixth resident is having a local holiday specially planned for him as, through discussion, it is felt this is what he would prefer. In-house there are range of activities including a Snoozelem Room, television, music, snooker table. As well as this, residents rooms are equipped with personal televisions, music, videos players, etc., which are used as the resident prefers. Externally there is a paved courtyard which is easily accessible and used very frequently by the residents. This are has been landscaped to provide different areas and places to sit and enjoy. Observations of staff interaction with residents during this inspection confirmed that there is a commitment to ensure residents are respected and provided with choice and freedom of movement. Residents were included in conversations and, as written in the care plans, there is a recognition that the residents may wish to spend time on their own and not always be in a large group. Residents are addressed by their Christian names or their preferred form of address which is included in the care records. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Personal and healthcare support is provided by a dedicated and experienced team of care staff and advice and guidance is incorporated into the care plans which enable staff to meet healthcare and personal needs in a professional, dignified and sensitive manner. EVIDENCE: Of the three care files examined, it was seen that the residents have their own “dedicated personal routines” information sheets in their care plans. These are written as if by the resident and talks about how they wish aspects of their care – rising, retiring, dressing, personal care, bathing – to be carried out. These are very useful documents and provide staff with an individual approach to care that has been built up over time and from experience and gives information that is not readily communicated by the residents themselves. Healthcare records are maintained but for the residents care files examined these have not been updated for sometime. For the two residents who have their own person centre plans in place the healthcare goals and action plans are clearly stated and, although the registered manager confirms these are being met, the current paperwork has no place to record this. This is something the manager is to address as a priority as it provides an essential record that the healthcare needs of the residents are being met. On one file it was noted that personal healthcare information was recorded on the front of Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 15 the file. Any decision to record information needs to be clear as to why and should be recorded in an appropriate and designated place in the care file. Survey forms were received from four healthcare professionals and all made very positive comments about the home. These included “all the carers know residents well, anticipating their needs and providing excellent care in all areas”. “I have always had good co-operation from all staff when making recommendations for clients care plans.” “I felt when I visited the staff at the home they were very forward thinking and inclusive of the relatives, service users and myself.” “The home communicates clearly and works in partnership – staff demonstrate a clear understanding of the care needs of the service users – any specialist advice I give is incorporated into the care plan.” The residents in this home are unable to manage their own medication which is managed by the home. During this inspection, medication records were examined and found to be accurately maintained. A requirement made during the last inspection has been addressed. Further advice is to be sought form the Pharmacist Inspector over the medication administration sheet provided by the Chemist. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No standards from this section were assessed during this inspection EVIDENCE: Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) No standards from this section were assessed during this inspection EVIDENCE: Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36 Residents are cared for by a professional, supportive, trained and very committed team of staff. The homes recruitment procedures are thorough and ensure the vulnerable residents are protected from abuse. Staff are well supported by the management team. EVIDENCE: It has previously been confirmed that staff are provided with roles and responsibilities as well as individual Job Descriptions for their designated role. From observations, discussions with a visiting relative and the registered manager it was confirmed that staff are very caring and supportive of the residents at the home. Because of the needs of the residents at this home staff have also to act as advocates on their behalf, particularly in the wider community. Some concerns were raised over the retention of staff in the home. It was confirmed that exit interviews are carried out for staff. Issues raised from these are currently under discussion. Staff spoken with also felt that at times a good level of staff is not maintained which means that individual activities may have to be curtailed or cancelled. Staff did confirm, however, that agency staff are brought in to cover vacancies when needed. This is something the registered manager could examine, along with the board of trustees, staff in Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 19 the home and also, perhaps, with other providers within the learning disability field of care. Staff records were seen and found to contain all the required information. The home has a thorough recruitment procedure in place which is adhered to for any recruitment of staff. Criminal Record Bureau Disclosures for all staff have been obtained and these were seen during this inspection. Staff records are individually maintained and kept securely in the main office. A number of staff have worked at the home for sometime, many have come from caring backgrounds with seven being qualified nurses. There is an ongoing training programme for staff which includes LDAF (Learning Disabilities Framework Award) and National Vocational Qualification Training to both Level II and Level III. As well as this, other training undertaken includes: Person Centred Thinking, Breakaway Techniques, Chest Physiotherapy, Health and Nutrition, Safe Handling of Medicines and Equality and Diversity. Discussions with staff confirmed that formal supervision is provided every 3 months and records were also seen for this. The registered manager was advised that the supervision notes should clearly indicate that all areas outlined in this standard have been covered. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, and 42 Experienced and qualified management staff run the home which results in the residents living in a well managed, comfortable and safe environment. EVIDENCE: The registered manager has achieved a range of qualifications, including the Registered Managers Award. Ongoing training was evidenced as courses have been attended in “Equality and Diversity, “Person Centred Thinking”, “Coach to Person Thinking”, “Aggression Management Update” and “Fire Lecture. Discussions with staff and members of the Board of Trustees confirmed their confidence in the management of the home. Staff confirmed that staff meetings are held every month and minutes provided for those who were unable to attend. There are monthly visits by the responsible person from the Board of Trustees who submits a report to the commission. No issues have been raised from these reports over the management of the home. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 21 The Pre-Inspection Questionnaire completed and submitted to the Commission confirms that regular maintenance checks are carried out on all systems and equipment within the home, including fire equipment checks and fire drills. A visit from the Environmental Health officer took place in September 2004. Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 4 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 4 3 3 3 3 4 x Standard No 31 32 33 34 35 36 Score x 4 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Primrose House (Morecambe) Ltd Score 4 2 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 3 x F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 23 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19 Regulation 13 and 17 Requirement A record must be maintained of all healthcare visits and specialist input Timescale for action 31.7.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard 36 6 13 12 19 42 Good Practice Recommendations The formal supervision of staff should include all areas outlined within this Standard Care documentation should be dated. Care plans should be reviewed on a monthly basis, with the formal yearly reviews continuing The activities matrix should be reviewed to avoid this being a tick list which may not accurately be maintained Weekly timetables for the residents should be dated The healthcare goals within the new person centred care plans must evidence that these are being addressed or met Any risk assessments carried out should be reviewed 6 weekly (or as necessary). Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 2nd Floor, Unit 1 Tustin Court Port Way Preston. PR2 2YQ 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 Primrose House (Morecambe) Ltd F57 F09 S9716 Primrose House V225846 260705 Stage 4.doc Version 1.40 Page 25 - 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!