Inspection on 12/09/07 for Queen`s Lodge,

This inspection was carried out on 12th September 2007.

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

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

Other inspections for this house

Queen`s Lodge, 04/10/06

Queen`s Lodge, 23/01/06

Queen`s Lodge, 20/09/05

Queen`s Lodge, 22/02/05

Queen`s Lodge, 29/09/04

Queen`s Lodge, 17/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Henry Nihill House

Birchwood

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

The Infirmary

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

CARE HOMES FOR OLDER PEOPLE Queen`s Lodge, 13 Queens Road Leytonstone London E11 1BA Lead Inspector Rob Cole Unannounced Inspection 12th September 2007 10:00 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 Queen`s Lodge, DS0000007224.V350559.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. Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen`s Lodge, Address 13 Queens Road Leytonstone London E11 1BA 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) 020 8558 6548 020 8558 6548 queens.lodge@btopenworld.com Mrs Miriam Binns Mr David Binns Mrs Miriam Binns Mr David Binns Care Home 16 Category(ies) of Dementia (6), Learning disability (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (16), Old age, not falling within any other category (16) Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2006 Brief Description of the Service: Queens Lodge is a family-run residential care home offering care and support to sixteen older people. The home is situated in a residential area in Leytonstone, in the London Borough of Waltham Forest. The home is close to local amenities and shops are within walking distance. The home has easy access to public transport; Leytonstone underground station is within walking distance of the home. The current range of fees charged by the home is between £442.52 and £578.10 per week. Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 12/9/07 and was unannounced. The homes two registered managers were present throughout the course of the inspection. The inspector had the opportunity of speaking with service users, their relatives and staff that work in the home. Evidence was also gathered from the observation of care staff carrying out their duties and interacting with service users. The inspection included a tour of the premises, and an examination of records and other documents. The home completed an Annual Quality Assurance Assessment prior to the site visit at the request of the CSCI, this was also used as part of the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, there are still some issues that the home must address. In particular, to help ensure that service users remain healthy, the home must ensure that all medications are appropriately stored, administered and recorded. Care plans must be further developed, and the home must ensure that all staff undertake appropriate adult protection training. Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that prospective service users are provided with sufficient information about the home to make an informed choice about moving in or not. This information s provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. The Statement says “The objective of Queens Lodge is to provide 24-hour care and comfort for the elderly in a family environment, with a warm and friendly atmosphere.” The Statement is of a good standard, and contains all information required by National Minimum Standards (NMS). It includes details of the management and staff team, including their experience and Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 9 qualifications, details of the range of services and facilities provided, and of the range of service users catered for. The Service User Guide includes details of the homes physical environment and of the complaints procedure. All service users or their relatives are provided with a copy of the Guide. Both the Guide and the Statement of Purpose are written in plain English. Contracts/statements of terms and conditions are in place for service users who are both publicly and privately funded. These have been signed by the service user (or their representative where appropriate) and by the homes manager. These include details of fees payable, and the terms and conditions of occupancy. The home has an admissions procedure in place. This states that pre admission assessments will be carried out, and that service users would be invited to visit the home before making a decision as to move in or not. Service users and relatives spoken to both confirmed that they were indeed given this opportunity. Service users initially move into the home on a trial basis for a period of six weeks. After this, a placement review meeting is held, which is attended by the service user, their relatives and their social worker. The home carries out pre admission assessments on any prospective service users. These cover needs around personal care, mobility and medication. The home does not provide intermediate care. Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home is able to meet the personal care needs of service users. However, more attention must be paid to service users health care needs. Service users must have access to relevant health care professionals including dental care, and medications must be administered and recorded as appropriate. EVIDENCE: All service users have an individual care plan in place, which are subject to regular review. Care plans cover needs around personal care, social and leisure needs and equalities and diversity issues such as religion and disability. However, care plans often state what the issue is that the service user requires support with, but do not provide any information about how this need is to be Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 11 met. For example, the care plan for one service user states that they suffer from depression, while another care plan states that the service user can be aggressive on occasions. But there was no information provided on how the home was meeting the service users needs around these issues. To help ensure that the home is able to meet all service users needs in a consistent manner, care plans must clearly set out the needs of service users, and how the home is to meet those needs. Risk assessments are in place for all service users, and are subject to regular review. Assessments cover risks associated with dementia, accessing the community and mobility, and identify strategies to manage and reduce any risks. All service users are registered with a GP. The homes manager informed the inspector that service users could keep the GP they had prior to admission where practical. Records are maintained of medical appointments, including details of any follow up actions required. Records indicated that service users have access to various health professionals, including CPN’s, opticians and chiropodists. Flu jabs have been booked for later this year. However, records indicated that service users do not have access to routine dental care. The manager informed the inspector that the home will make an appointment for a service user to see a dentist, if there is a specific need, but that they will not otherwise have routine dental checks. Records indicated that several service users have not had any access to dental care in the past two years. It is required that service users have routine access to all relevant health care professionals, including dental care. Medications are stored in a locked cabinet, which is secured to the wall. Some medications are stored in the kitchen fridge, but these were not kept in a secure box, and this must be addressed. Staff undertake training before they administer medication. No service users currently self medicate or are on any controlled drugs. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. Medication Administration Record (MAR) charts are maintained. These included several instances where correction fluid had been used to make a correction on the MAR chart. To ensure that MAR charts are clear and transparent, it is required that correction fluid is not used on them. One service user has been prescribed LORAZEPAM solution. This has been entered on the MAR chart, although it has not been signed as been administered since the 16/8/07, although staff informed the inspector that they have been giving the medication, but not signing for it. It is required that all medications are appropriately administered and recorded, to help ensure that service users receive any medications that they have been prescribed. The manager informed the inspector that service users can remain in the home with a terminal illness, so long as the home is able to meet their medical Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 12 needs. The home has sought and recorded the views of service users on the arrangements to be made in the event of their death. Through observation and discussion there was evidence that the home treats service users with dignity and respect. Staff were seen to interact with service users in a sensitive and respectful manner. Service users are encouraged to manage their own personal care as much as possible. Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are supported to live valued lives. Appropriate social and leisure activities are provided, and the food is of a satisfactory standard. EVIDENCE: Service users attend various day services. Service users with learning disabilities attend a lunch cub organised by MENCAP, where they have the opportunity to develop and maintain relationships with other people. Other service users attend a social club for adults with mental health issues. These clubs help the home to meet the equality and diversity needs of service users. Other service users attend the Jubilee Centre, where they have access to a variety of activities, including painting, knitting and dancing. The home also accesses the Disability Resource Centre, which arranges various day trips, for example to Southend. Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 14 The home arranges for various outside entertainers to visit, including singers and comedians. Mobility London visit the home, and provide various activities such as dancing, ball games and various exercises which help to improve service users fitness and mobility. A catholic priest visits the home to support service users with their religious needs. Service users also have access to a variety of activities in-house, including TV, music games and sing-a-longs. Two service users are from Jamaica, and there was evidence that the home seeks to meet their cultural needs, for example one regularly visits a Caribbean hairdressers, while the home cooks Jamaican food on occasions. Visitors are welcome to the home at any reasonable time. Service users can see visitors in private if the so wish. During the course of the inspection, the inspector spoke to a visiting relative, who informed the inspector they were very happy with the level of care and support provided. They informed the inspector that staff were always friendly, and that they were kept informed of any significant events. They commented that “I could not wish for better.” There was evidence that the home seeks to respect service users privacy and choice. Service users are given their own mail to open, and have access to a telephone. One service user said “I can get up and go to bed when I like.” Records are maintained of menus, these evidenced that service users are offered a healthy, nutritious and balanced diet. On the day of inspection service users were offered a choice of lamb stew or roast chicken for lunch, both of which appeared appetizing. Two service users have diabetes, staff demonstrated a good understanding of this in relation to their diet. Service users spoken to said they were happy with the quality of the food provided, one commented that “The food is ok here, you get big portions.” Staff were seen to offer drinks and snacks to service users throughout the course of the inspection. There was evidence that the home routinely uses fresh produce in its cooking. The kitchen was clean and tidy, and food was stored appropriately. Records are maintained of fridge and freezer temperatures. Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that the home has appropriate policies and procedures in place around complaints. However, service users would further benefit from staff receiving appropriate adult protection training. EVIDENCE: The home has a complaints log, although the manager informed the inspector that the home had not received any complaints since the previous inspection. The home also has a complaints procedure. This included timescales for responding to any complaints received, and contact details of the CSCI. A copy of the procedure was on display within the home. Service users and their relatives spoken to demonstrated a good understanding of who they could complain to if they so wished. The home has a copy of the Local Authority adult protection procedure, and also its own policy on adult protection. However, this was not in line with current legislation, for example it made no reference to the homes legal responsibility to report any allegations of abuse to the host Local Authority, and must be amended accordingly. Staff spoken to demonstrated only a Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 16 limited understanding of their roles and responsibilities with regard to adult protection issues, and it is required that all staff who work at the home receive appropriate training in adult protection issues. The inspector was satisfied that the legal rights of service users are protected. For example, all service users are on the electoral register, and the manager informed the inspector that service users would be able to vote in elections if they wished. Queen`s Lodge, DS0000007224.V350559.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is suitable to meet its stated purpose with regard to its physical environment. The home is generally well maintained, both internally and externally, and service users are provided with adequate private and communal space. EVIDENCE: The home is situated in a quiet residential area of Leytonstone, in the London Borough of Waltham Forest. It is close to shops, transport networks and other local amenities. The home is built over four floors, and is in keeping with other homes in the vicinity. The home is generally well maintained, both externally and internally. Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 18 The homes communal areas consist of a sitting room, a dining room, a kitchen and a well maintained garden. This contained garden furniture, and was seen to be used by service users on the day of inspection. Service users were observed to move around communal areas freely. The homes décor was of a satisfactory standard, while furniture and fittings were well maintained and domestic in character. The home has two bathroom/toilets, two shower room/toilets, and two toilets on their own, which are sufficient in number to meet the needs of service users. Toilets have been adapted with hoists and rails to make them accessible to service users, thus helping to meet their needs with regard to equalities and diversity issues. All bathrooms were fitted with a working lock, which included an emergency override device. Bathrooms were clan, tidy and free from offensive odour. The home is registered to provide care and accommodation to sixteen people, and comprises of two double bedrooms and twelve single bedrooms. Double rooms have screening in them to provide privacy. All bedrooms have hand basins fitted. Bedrooms meet NMS on size requirements. Service users have been able to personalise their bedrooms to their own individual taste, for instance with televisions and family photographs, and service users are able to bring their own possessions to the home with them, such as book cases. Rooms contained adequate furniture, including table, chairs, wardrobes and a chest of draws. Curtains, carpets and bedding were well maintained and domestic in character. All bedrooms contained central heating, and heating appliances had appropriate safety coverings. Rooms had adequate natural light and ventilation. The home has various adaptations in place to make it more accessible to service users. As mentioned, bathrooms and toilets have been adapted, and a stair lift has been installed. There is a ramp leading up to the front door of the home. The homes laundry facilities are appropriate in scale for the home, and hand washing facilities are situated around the home. Staff are provided with protective clothing, such as gloves and aprons to help prevent the spread of infection. COSHH products were stored securely. Queen`s Lodge, DS0000007224.V350559.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home is staffed in sufficient numbers, and that staff have a good understanding of their roles and responsibilities. However, to help ensure that staff are recruited appropriately, it is required that CRB checks are carried out on all staff prior to them commencing work at the home. EVIDENCE: The home provides 24-hour support, including waking night staff and an emergency on-call procedure. There was a staffing rota on display, this accurately reflected the staffing situation on the day of inspection. All staff are provided with a copy of their job description. Through observation and discussion there was evidence that staff have a good understanding of their roles and responsibilities, and that they have developed good individual relationships with service users. Staff were seen to interact with service users in a respectful and friendly manner, for example support at mealtimes was provided in a relaxed and unhurried manner. Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 20 The home has various employment related policies in place, for example around equal opportunities and recruitment and selection. The inspector checked staff employment files, these were found to contain proof of ID and employment references. However, they did not all contain evidence of a CRB check been carried out by the present employer. It is required that the home carries out CRB checks on all staff prior to them commencing work at the home. Of the nine care staff currently employed at the home, five have successfully achieved an NVQ Level 2 in Care or equivalent qualification. The manager informed the inspector that more staff are expected to commence such a qualification in the near future. Records are maintained of staff training. Recent training includes manual handling, fire safety, infection control and dementia. The manager informed the inspector that staff have been booked to attend training on working with adults with mental health issues later this month. Queen`s Lodge, DS0000007224.V350559.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37 and 38. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the homes managers are suitably experienced and qualified to manage this home. EVIDENCE: The home is jointly managed by the two proprietors of the home, and both are registered with the CSCI. The have managed the home since 1985. Both have many years experience of working in social care, and both have successfully achieved the Registered Managers Award. Staff were seen to interact with the management team in a relaxed manner, and service users and their relatives Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 22 informed the inspector that they found the managers to be approachable and accessible. The home a set of policies and procedures in place. Those checked by the inspector were of a satisfactory standard, including the polices on equal opportunities and medication, and they were in line with NMS. (The one exception been the policy on adult protection as previously mentioned in this report). Record keeping was of a generally good standard. Confidential records are stored securely, staff and service users can access their records as appropriate. Staff meetings, supervisions and care plan reviews all contribute to the quality assurance process within the home. Copies of previous inspection reports are available to view. The home issues questionnaires to service users and their relatives to gain their feedback on the running of the home. Completed questionnaires seen by the inspector contained generally positive feedback, for example one service user stated on their questionnaire “Meals are like home cooking.” There was evidence that staff receive regular formal supervision from the homes manager. Records are maintained of supervision, and staff have access to their supervision records. Records indicated discussions around training needs and service user issues. Fire extinguishers were situated around the home, these were last serviced in May 2007. Fire alarms are tested by the home weekly, and were last serviced on the 7/6/07. The home holds regular fire drills. The home had in date safety certificates for gas safety, PAT testing and electrical installation. Hot water and fridge/freezer temperatures are regularly checked. COSHH products are stored securely. The home has in date employer’s liability insurance cover in place. Queen`s Lodge, DS0000007224.V350559.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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Queen`s Lodge, DS0000007224.V350559.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 OP7 Regulation 15 Requirement The registered person must ensure that comprehensive care plans are in place for all service users. These must identify service users needs, and demonstrate how the home is able to meet those needs. The registered person must ensure that service users have routine access to health care professionals as appropriate, including dental care. The registered person must ensure that all medications in the home are stored securely, including those medications that are stored in a fridge. The registered person must ensure that correction fluid is not used on Medication Administration Records. The registered person must ensure that all medications are administered and recorded as appropriate. The registered person must ensure that the home has an adult protection procedure, which is in line with current DS0000007224.V350559.R01.S.doc Timescale for action 31/12/07 2. OP8 13 31/12/07 3. OP9 13 30/09/07 4. OP9 13 30/09/07 5. OP9 13 30/09/07 6. OP18 13 31/10/07 Queen`s Lodge, Version 5.2 Page 25 7. OP18 13 and 18 8. OP29 19 legislation. The registered person must ensure that all staff working in the home undertake appropriate training in adult protection issues. The registered person must ensure that CRB checks are carried out on all staff prior to them commencing working at the home. 31/12/07 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queen`s Lodge, DS0000007224.V350559.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queen`s Lodge, DS0000007224.V350559.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. 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