Inspection on 21/02/07 for Sedgemoor Care Home

This inspection was carried out on 21st February 2007.

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

Sedgemoor Care Home 02/11/09

Sedgemoor Care Home 26/08/09

Sedgemoor Care Home 17/04/08

Sedgemoor Care Home 04/10/07

Sedgemoor Care Home 28/01/06

Sedgemoor Care Home 26/11/05

Sedgemoor Care Home 02/03/05

Sedgemoor Care Home 19/10/04

Sedgemoor Care Home 25/02/04

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 Sedgemoor Care Home 41 Sedgemoor Road Norris Green Liverpool L11 3BR Lead Inspector Lesley Owen Key Unannounced Inspection 21st February 2007 11:00a 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 Sedgemoor Care Home DS0000035911.V327644.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. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sedgemoor Care Home Address 41 Sedgemoor Road Norris Green Liverpool L11 3BR 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 256 1810 www.liverpool.gov.uk Liverpool City Council Ms P Donnellan Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of thirty (30) adults may be accommodated. Thirty(30) shall be in the category of OP. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection One (1) named female service user under 65 years of age within an overall total of 30 (OP) 28th January 2006 Date of last inspection Brief Description of the Service: Sedgemoor is registered to provide personal care for 30 people of both sexes over the age of 65 years. It offers respite care, short-term care as well as permanent residential care. The home also provides day care for people from the local community. Sedgemoor is a purpose built single storey building, which opened in 1993. The home is owned and managed by Liverpool City Council. The home is located in the Norris Green area of Liverpool. Although the home is some distance from local shops and amenities, they are easily accessible via a bus service that stops directly outside the home. The home comprises of three separate units and an administration block which all open out from a central atrium. Each unit has ten single en-suite bedrooms, a self-contained kitchen/dining area and two lounges. There is a garden area on all sides of the home. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit began at 11.00am and took place over seven hours, a senior carer was on duty at the start of the inspection. The inspection was completed with the deputy manager. During the visit residents, staff and a visitor to the home were spoken to. All relevant documents for residents and staff were reviewed. A tour of the building was made and a sample of maintenance records were seen. In addition the manager completed a preinspection questionnaire which provided the inspector with information and survey forms were sent out for service users to complete if they wished. What the service does well: What has improved since the last inspection? Staff who administer medication in the home had recently completed training in the safe administration of medicines which was externally assessed. Activities continue to be developed in the home and two staff have recently completed training in providing armchair exercises. On-going training in core subjects is provided and a number of staff have attended training in specialist areas. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Sedgemoor Care Home DS0000035911.V327644.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 Sedgemoor Care Home DS0000035911.V327644.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): 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prior to service users being admitted to the home an assessment of their needs had been undertaken. EVIDENCE: As part of this visit the inspector case tracked a number of resident’s personal files from pre-admission up to date. All files seen contained care management assessments completed by a social worker. The inspector was able to confirm that new service users are admitted to the home following an assessment that includes meeting the prospective service where possible and if appropriate their representative. Information obtained through discussion and from survey forms returned confirmed that residents were visited at their home prior to their admission to the home and encouraged to visit the home if possible. Exceptions do arise when staff cannot assess the resident or receive documentation prior to admission and in this situation it understood that a member of the management team would undertake the initial assessment. This process would also include discussion with social/health care professionals and written information using a pre- assessment form. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 9 From the information obtained from the admission assessment and care plan where provided, staff at the home draw up a care plan with the involvement of the resident, their family / representative as appropriate, and key staff. Where possible the care plan drawn up is signed by the resident. All prospective residents where possible, are invited to the visit the home to meet with the staff and other residents before making a decision about their future care. They are welcome to stay for a meal, the day or longer if they wish. This practice is encouraged, although there may be occasions when it is not practical i.e. when a service user is admitted directly from hospital. A number of residents whose care files were seen had previously spent periods of respite at the home and one person spoken to confirmed that this had given them valuable information about the service provided before they made the decision to enter full time residential care. The current charges at Sedgemoor Care Home are £350.24 per week. Additional charges are made for hairdressing, daily papers and magazines, some toiletries and £7 for chiropody, this information was provided in the preinspection questionnaire submitted prior to the inspection. Sedgemoor does not provide Intermediate Care, so Standard 6 is not applicable. Sedgemoor Care Home DS0000035911.V327644.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual care plans of residents evidence how their identified needs are to be met on a daily basis. Staff must follow the policies and procedures in relation to the management of medicines in order to ensure residents safety. EVIDENCE: The inspector viewed a sample of care plans completed for residents admitted to the home since the last inspection, which also included evidence of risk assessment. Care plans had been prepared for each resident and where possible residents were involved with their preparation. Where risks had been identified the steps taken to minimise the identified risks had occasionally not been recorded. This should be addressed. The records examined showed that care plans were reviewed on a monthly basis and amended where required. Not all documentation and assessments completed were signed by the person completing the documentation, this should be addressed. Where a resident cannot sign their care plan or do not wish to be involved in the process , this should be recorded. Daily records are Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 11 maintained for each resident and it is recommended that a record is maintained of the frequency of night checks made. It was evidenced from discussion, observation and documentation that staff at the home promote and maintain residents health care needs and arrangements are made for appropriate healthcare provision. A designated district nurse visits the home on a weekly basis and will see residents that staff may have a concern about. In an emergency situation arrangements are made via the residents GP. The inspector was able to speak with the nurse at the home on the day of the visit who was complimentary of the care provided by staff. The home arranges for residents to see the optician, chiropodist and dentist as necessary. The district nurse provides the required treatment if a resident develops a pressure area. Records of all visits by or to health care professionals are maintained. Care staff accompany residents to outpatient appointments when possible or to other appointments as necessary. The home has a draft copy of the revised policy for the receipt, recording, storage, handling, administration and disposal of medication. It is understood that this policy has not been approved as a working policy document, this must be addressed in order that staff have clear guidelines and parameters to work within. All staff who administer medication had recently completed certificated training in the “Safe Handling of Medicines”. Inspection of completed Medication Administration Records (MAR sheets) indicated the following need to be addressed as not all staff were following the procedures in relation to recording. • on occasions there were omissions in recording when medication was administered. • the date when medication had been delivered to the home had not always been recorded and medication • when medication is recorded on the MAR sheet by hand two staff must sign. Where residents self administer medication a written risk assessment must be undertaken and be available on file. There was evidence that residents right to privacy and dignity was both acknowledged and practiced. The maintaining of residents dignity and privacy is included in the Statement of Purpose and the homes policies and procedures expect that all residents will be treated with respect. All bedrooms are fitted with locks, as are bathrooms and w.c. doors. The senior person on duty carries a master key to enable bedroom doors to be opened in an emergency and all bathrooms and w.c’s can be opened from the outside in an emergency. Staff were observed to knock on bedroom doors before entering and all service users are free to meet with their visitors in the privacy of their own bedroom or in one of the communal areas. A pay telephone is available for service users. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily routines in the home were flexible so residents were able to exercise choice, and have some control over their lifestyle. Activities provided in the home are interesting and varied to cater for a wide variety of interests. EVIDENCE: The daily routines in the home were observed to be as flexible as possible, and residents were encouraged to make their own decisions about how to spend their time. Residents are encouraged to exercise control over all aspects of their daily life with as little or as much support from staff as required. This was confirmed during discussions with residents and through observation. During this visit residents were observed spending time in their bedrooms, in the lounge or atrium areas or as for one resident going out with a member of staff to do some personal shopping. Residents are encouraged to look after their own finances or a relative /representative to manage them on their behalf. Where any money is managed for residents records of any money spent are recorded and receipts kept. Residents finances were not checked during this visit. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 13 The home does not have an activities coordinator and staff share the role of supporting activities, however one senior member of staff has developed a special interest in promoting activities in the home and has assumed responsibility for coordinating a number of activities. Various activities are provided both in-house and outside the home. A list of weekly activities available is displayed which includes in-door games and exercise sessions. The senior carer and another member of care staff have recently completed a course on armchair exercises and it is intended to incorporate aspects from this course to develop the exercise programme in the home. All residents spoken to confirmed that varied activities were available in the home. Each month an informative newsletter is produced by a senior carer, which gives information on forthcoming events, results of competitions and includes a write up about different areas of Liverpool is produced. The inspector was provided with the last three newsletters which gave valuable information about what had been happening in the home. Outside entertainment is arranged when possible, and a bar area has been created in the atrium for use by residents. Since the last inspection there have been a number of trips out the most recent to the pantomime which those who went enjoyed. During a walk round the building bedrooms seen were individual and personalised. Residents can bring with them their own personal possessions when they come to live at the home as long as they conform to the appropriate fire safety standards. All meals are prepared in the main kitchen and transferred via heated trolley to the individual units. There are three dining rooms one for each of the units, which were decorated to a good standard and the tables were well presented with suitable crockery and cutlery. Menus are rotated on a four weekly basis There’s always a choice of two main meals at lunch and a choice of a hot or cold meal at tea time. Both hot and cold drinks are available throughout the day. Residents are consulted by care staff on a daily basis as to their choice of meals and were complimentary of the food provided. Residents can either take their meals in the dining room or in the privacy of their rooms. Staff are always available to assist service users in the dining room if assistance is needed or requested. Records are kept of individual residents likes and dislikes, individual preferences and dietary needs. Discreet observation confirmed that meals were relaxed and unhurried. Comments made by residents were complimentary about the food provided. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for handling complaints are in place and concerns are handled appropriately. All staff receive training on adult protection issues to ensure the protection of residents. EVIDENCE: The home has a copy of the Liverpool City Council Complaints Procedure and the document “Have Your Say” gives details of who to contact and timescales for response. Basic information about making a complaint is also displayed in the foyer of the home. Since the last inspection four complaints have been recorded in the record kept by the home and were resolved. CSCI has received no complaints since the last inspection. The home has an abuse policy and procedure and a whistle blowing policy, and if an allegation of abuse were made the Liverpool inter-agency adult protection procedures would be followed. Training is provided for staff is on-going in recognising abusive practices. The home has a policy relating to the handling of service users money. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sedgemoor provides residents with a safe, comfortable and homely environment, where the standard of hygiene maintained is good. EVIDENCE: Sedgemoor is a purpose built residential care home, which is well maintained. The home stands in its own grounds, and there are a number of secure areas available for use by residents. The home comprises of three units, each having two lounges and a dining room. A large lounge/atrium is located in the central area of the home. One of the lounges in each unit is designated as a smoking area. The home is on a single level and does not present problems for wheelchair users or people who have mobility difficulties. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 16 All bedrooms have en-suite facilities and there are additional bathrooms and toilets situated throughout the home Not all bedrooms were seen during this inspection. Those bedrooms seen were individual and personalised. Residents are able to bring items of furniture into the home subject to them meeting the required fire standards. Furnishings seen were of good quality. All bedroom doors are lockable and staff hold a master key to gain access in an emergency. A lockable facility is provided in each bedroom. The radiators in the home are low surface temperature to minimise the risk of accidents. Hot water temperatures are tested monthly. There is appropriate lighting in bedrooms and communal areas. The standards of hygiene maintained in the home are good and areas home seen were viewed to be clean and free from offensive odours. The home has an infection control policy. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment and selection procedures ensure resident rights are protected. The home benefits from having a stable and experienced staff group. All new staff receive induction training. EVIDENCE: Staff are deployed throughout the home to ensure the needs of residents are met. There is always a senior member of staff on duty. At night the home provides three waking night staff one of whom is a senior carer .In addition to care staff sufficient numbers of ancillary staff are employed to maintain the environmental and nutritional needs of residents. Residents spoken to during the visit said they were happy with the care and support they receive from staff. Comments received from survey forms returned included “excellent standard of care and attention”, “nothing is too much trouble extra pillows, a fan, cup of tea in the small hours to comfort and a chat”. The City Council has clear Recruitment and Selection Procedures that are followed for all permanently employed staff. The staff files of the two staff employed since the last inspection were examined. Files contained application forms, references and CRB and POVA information was also evident. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 18 New staff receive induction training and undertake foundation training. The inspector was able to speak to one of the newer members of staff who confirmed that they had been provided with induction training. Staff must ensure that all areas of the induction documentation are signed. The inspector was provided with information about the training provided since the last inspection and included training in moving and handling, health and safety. first aid, food hygiene, infection control and falls risk assessment. Specialist training had been provided in working with people with dementia, medication and how to support a person who is peg fed. Training planned includes further staff to be provided with training in working with people with dementia and challenging behaviour. NVQ training is on-going and a number of staff are currently undertaking levels 2 and 3. The staff team should be commended information provided in the pre-inspection questionnaire confirmed that 22 of the 26 care staff at the home have completed NVQ2 or above. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of training in relation to health and safety issues needs to be improved to ensure the continued health, safety and welfare of service users. EVIDENCE: The registered manager has many years of experience in caring for the elderly and is currently working towards a relevant qualification. She is supported by the deputy, an assistant manager and seven senior carers who cover both day and night shifts. The home has good systems in place to obtain feedback from residents and this is gathered either by completing surveys or by attendance at residents meetings. Results of surveys undertaken are published in the monthly Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 20 newsletter for residents and the inspector was provided with the results of the last survey which were positive. The Regulation 26 visits are carried out by the Service Manager and a copy of the report provided after the last visit undertaken this month was available in the home. The manager must ensure that copies of these visits are available for inspection. Staff records maintained showed that staff were not receiving formal supervision at the required intervals. This is something that the management must address. It is understood that senior care staff have received training in providing supervision and senior night carers provide this for night staff. Consideration should be given where appropriate to delegate the providing of supervision to senior day carers. Information provided in the pre-inspection questionnaire indicates that safety certificates were up to date. A number of records were viewed which included fire safety, servicing of hoists, gas safety and electrical wiring certificate, with the exception of fire safety all were found to be up to date. Examination of fire records indicated that that the fire alarm was being checked fortnightly instead of weekly, fire drills had not taken place for some considerable time and fire training for staff was not up to date. This was brought to the attention of the deputy manager and manger and a full fire drill and training for staff on duty undertaken over the three days following the inspection and confirmation that this had taken place faxed to CSCI. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 21 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x 2 x 2 Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement The registered person is required to make arrangements for the recording, safe handling, safekeeping, safe administration and disposal of medicines received into the home. The following issues were identified and must be addressed: • There were omissions in recording when medication had been administered. All medication administered must be signed for. • When service users self medicate a risk assessment must be completed.. • All sections of the MAR sheet must be completed in order that an accurate audit of medication can be undertaken. A written risk assessment must be undertaken where residents self-medicate. The registered person is required to ensure that the fire alarm is tested weekly, fire drills undertaken and staff receive fire training at the appropriate intervals and this is recorded DS0000035911.V327644.R01.S.doc Timescale for action 21/02/07 2 OP38 23 (c) & (d) 31/03/07 Sedgemoor Care Home Version 5.2 Page 23 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 3 4. 5 Refer to Standard OP1 OP7 OP9 OP30 OP31 OP36 Good Practice Recommendations To ensure the Statement of Purpose and Service User Guide are reviewed at regular intervals. To record how often checks are made throughout the night To ensure the draft medication policy is approved as a working policy document, in order that staff have clear guidelines and parameters to work within. To ensure all documentation relating to induction training is signed. The registered manager should achieve an NVQ level 4 qualification in management and care. To ensure staff receive supervision at least six times each year. Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Sedgemoor Care Home DS0000035911.V327644.R01.S.doc Version 5.2 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. 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