Inspection on 06/03/07 for Spencefield Grange

This inspection was carried out on 6th March 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

Spencefield Grange 04/03/10

Spencefield Grange 23/11/09

Spencefield Grange 16/02/09

Spencefield Grange 13/12/05

Spencefield Grange 26/05/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Spencefield Grange Davenport Road Leicester Leicestershire LE5 6SD Lead Inspector Susan Lewis Unannounced Inspection 10:00 6 March 2007 th 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 Spencefield Grange DS0000064398.V321217.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. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spencefield Grange Address Davenport Road Leicester Leicestershire LE5 6SD 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) 0116 2418118 0116 2418118 Debbie@hicare.co.uk HiCare Limited Mrs Deborah Crawford Care Home 56 Category(ies) of Dementia - over 65 years of age (34), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (31), Old age, not falling within any other category (56), Physical disability (37), Physical disability over 65 years of age (56) Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No person under 55 years of age who falls within category PD may be admitted into the home. No person who falls in category MD(E) may be admitted to the home when 31 persons in total of this category are already accommodated in the home. No person who falls in category DE(E) may be admitted into the home when 34 persons who fall within this category are already accommodated in the home No person who falls within category PD may be admitted to the home when 37 persons who fall within this category are already accommodated in the home. 13th December 2005 Date of last inspection Brief Description of the Service: The fees for 2006/07 are from £410 - £ 450. A copy of the most recent inspection report is available in the reception area. The home provides accommodation for 56 people and is owned by Hicare Limited. It is located in a quiet suburb on the outskirts of the city of Leicester and has access to a regular bus service. The building is a modern purpose built service offering accommodation on ground and first floor level. Bedrooms on the first floor are accessed by a shaft lift. There is ample car parking facilities to the front and side of the home. At the rear of the home there is an extended patio terrace with garden furniture and ornate water fountain. The garden has level access for people with impaired mobility. There are suitable facilities to support people with physical disabilities such as handrails and other specialist equipment for the prevention of pressure sores is also available through the district nursing service. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting residents and tracking the care they received through looking at their records and observing staff that provide their care. Two hours were spent observing the care given to a small group of people. All observations were followed up by discussions with staff and examination of records. As observation was used during this inspection residents were not spoken with on this occasion. The inspection was unannounced and took place over 71/2 hours one Tuesday in March 2007, and was conducted by one inspectors as part of the annual inspection process. A partial tour of the building took place and a selection of residents’ bedrooms was inspected. Other information that was used to inform this report was the pre-inspection information provided by the registered manager, accident and incident reports received since the last inspection as well as the previous inspection report. What the service does well: Residents live in a pleasant and well-maintained environment, where their cultural, spiritual, social and care needs are met. Staff are well trained and feel supported by management to perform their role in a safe and competent manner. Residents observed during this inspection appeared relaxed and happy with positive interactions with staff and each other. The meal was observed and it appeared appetising and residents were given a choice, residents with special dietary needs whether through their culture or their health needs had these met. Visitors commented that the food was very good and that they were happy with the care their loved one received. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 6 Activities are provided through the activities organiser and these are appropriate to the needs and abilities of the residents. What has improved since the last inspection? What they could do better: Overall the standard of care within the home is very good and residents are well supported. However there are some recommendations for good practice made in this report. The care plans could provide more personal detail of residents specific needs and show how they are involved in creating and reviewing care plans. Although medication was handled carefully and following good practice it is recommended that when medication is returned to the pharmacist that the ‘returns’ book is signed and dated by staff from the home to provide a clear audit trail of medication coming into the home being administered and leaving the home. It is also recommended that a copy of what staff must do in the event of a drugs administration error be placed in a prominent position so that staff have immediate access to that information should a drugs error occur. Information is available in the Service User Guide regarding advocate services, however it is recommended that residents and relatives are given more Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 7 information about this in more prominent locations to ensure that they are fully aware that this service is available to support them. The home has a thorough complaints policy and ensures residents and their relatives are able to complain, it is recommended that where letters in reply to complaints are stored on individual residents files that this is recorded in the complaints file to show that the complaints procedure has been followed. Staff files were very clear and contained all the information legally required to show that every appropriate step has been taken when recruiting staff. The manager uses a matrix that records when the Criminal Records Bureau was sent for and the reference number. The actual copies of the Criminal Records Bureau are stored centrally. It is recommended that the matrix include when the Criminal Records Bureau was received and when the POVA First check was received. This means all the relevant information the manager needs is at hand. 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. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Residents only move to the home following an assessment and are assured that their needs would be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were viewed for the purpose of this inspection and each plan had a full assessment of nee provided by Social Services, the manager also carries out an assessment and staff spoken with confirmed that the manager usually visits the prospective resident either at home or in hospital. Staff also said that when a new resident arrives at the home their care needs are discussed with all staff and everyone is made aware of their needs including any special dietary requirements. This ensures that the home are aware of the residents needs prior to moving into the home and are sure that they are able Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 10 to meet them. The assessment then informs the care plan ensuring that staff are fully aware of the needs that must be met. Intermediate care is not provided in this service. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Residents’ social, personal and health care needs are set out in a care plan, their health care needs are fully met and residents are protected by the procedures for handling medication. Residents’ dignity is supported and maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents each have a care plan that identifies their needs and how the needs are to be met. The care plan format used is one recommended by East Midlands Care Association and provides guidance on areas that should be covered. The home is particularly strong in ensuring residents cultural needs are identified and provision made to meet them. Staff too were very aware of residents cultural needs and what support was required. Although generally care plans were good some did lack detail in some identified areas such as Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 12 communication. In discussion with staff they clearly understood what needed to be done and this was backed up in observation however it was not clearly detailed in the plan. This was raised with the manager and details were added during the inspection. It is strongly recommended that where residents have specific needs that these are fully detailed in the plan to ensure that all staff can refer back and ensure that they are following excepted practice. There was evidence that plans were reviewed but no written evidence that residents were involved but in discussion with staff they were able to describe how residents were involved in discussions in reviewing care plans. It is recommended that this information be included in review notes on care plans. In discussion with staff and from diary notes it was evident that resident health care needs were being met evidence was seen that equipment to minimise the risk of pressure sores was obtained for those residents who required it. Staff spoken with were aware of all residents needs and were supported in a handover system in ensuring that any concerns were passed to each shift to monitor. Evidence was seen in care plans that residents weight was monitored with follow up taken if a resident loses significant amounts of weight. It also included information where a resident had been fasting and therefore had lost weight. This is good practice. Medication was stored in a locked trolley and a locked cupboard. Records were in order and staff were observed administering medication appropriately. Controlled drugs were stored in a separate locked cupboard and were recorded both in their own book and in the Medication Administration Records with two signatures to show they had been administered correctly. The medication returns book was not always dated and so made auditing more difficult and although the person collecting them signed the returns book a representative from the home did not sign them. It is recommended that the returns book is always dated and that someone from the home countersigns to say that the drugs have left the building. It is also recommended that a copy of the homes Drugs Error policy is placed in a prominent place for staff in case such an event takes place to ensure they have the information to hand quickly. A requirement was made at the last inspection to seek advise from the community pharmacist regarding a resident who self medicates, evidence was Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 13 seen that this has now been done and that the advise was followed. This requirement is met. During the observational period of the inspection from 11.10 am to 1.10pm four residents were observed in both the lounge then the dining room During this time residents had their midday meal. The four residents were observed mostly in a positive mood and interacted well not only with staff but with other residents in the room. Staff spoke to residents politely supporting their dignity and when they asked a question they waited for an answer not just rushing ahead of the resident or assuming a reply. All staff observed during this period were seen to treat the residents with respect, choices were given and affection was seen between staff and residents. A visitor spoken with commented that staff were lovely and ‘it was a really lovely place’. Visitors were observed throughout the day and staff were seen interacting in a positive manner. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Residents are supported to maintain their cultural, religious and social activities as well maintain contact with their family and friends in the community. Residents are provided with nutritious meals in a pleasant dining room at times convenient to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken with said that breakfast was flexible and residents got up when they wanted to. During the tour it was evident that residents took breakfast when they wanted to and it was not at a fixed time. Evidence was seen of a variety of different activities through the day and some residents assisting with housekeeping tasks within the home such as wiping tables and preparing them for the next meal. This is good practice as it involves residents in all aspects of the running of the home. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 15 Evidence was seen in care plans and during the tour that residents cultural and religious practices were supported and encouraged. Where residents were fasting as part of their faith, arrangements were made to enable them to take their breakfast early and eat their meal after sunset. This ensures residents are able to continue with their beliefs and activities that are important to them within the home. Evidence was seen that visitors are encouraged to visit the home and are able to have a meal with their loved one if they chose to. In discussion with the manager on how residents were supported who had no relatives or lacked capacity it was clear that information regarding other support services were available in the Service User Guide, however residents and relatives were not clearly sign posted to this. It is recommended that information regarding advocate services is placed in a prominent area to ensure relatives and residents are made aware of it. The midday meal was observed and it appeared wholesome and nutritious, staff were heard to offer residents a choice of hot meal and where a resident did not want either staff asked the resident if something else could be brought. This was then brought for the resident. This ensures that residents are supported to have a varied and nutritious diet. Where residents needs special diets this is documented in care plans the cook is aware of providing appropriate meals for diabetics and soft diets as well as where cultural needs must be met. Care staff spoken with were also aware of residents dietary needs and how these should be met. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents are supported to complain and there are robust procedures in place to protect them from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission received one complaint since the last inspection regarding the home and looking at records as part of the inspection there was no evidence to support the complaint. The home received two complaints and from evidence seen these were both dealt with according to the home complaints procedure. However due to how the information is stored it was not always clear what the response was. It is therefore recommended that where response letters are stored on the individual residents file then this should be sign posted on the complaint documentation. In discussion with staff it was clear that they understood the complaints procedure and their responsibility to support residents if they wanted to make a complaint. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 17 In discussion with staff they confirmed that they had received training in recognising abuse and what they must do if they suspected it. They were clear that they had a responsibility to ensure that residents were safe and free from harm. They were able to say what the policy was in protecting residents’ personal money was and they confirmed that this was followed. This protects residents from abuse. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is excellent. Residents are supported by living in a well maintained and pleasant environment that promotes residents cultural needs. The home has good infection control procedures that protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was evidence of on going refurbishment to the home, currently the dining room is being extended to accommodate the residents in more comfort particularly where residents are in wheelchairs. Two further lounges are being built in an extension again to provide more flexible accommodation. This is good practice. The home was clean and pleasant and the bedrooms viewed as Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 19 part of the tour were well equipped and spacious. There was evidence that where married couples share a room the second bedroom has been equipped as a sitting are for them again this is good practice. Bedrooms were personalised and in some cases supported the residents’ cultural and religious needs. Throughout the home there were pictures on the wall representing a variety of cultures. The laundry room is able to meet the needs of residents and promotes good infection control. Staff were observed following good hygiene practice throughout the day. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 20 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. There are sufficient staff on duty to meet the needs of residents and residents are protected by the home’s recruitment practices. Staff receive training to enable them to do their job. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were observed throughout the day in sufficient numbers to meet the needs of the residents. Staff spoken with said that usually there were enough staff covering each shift and in the event of sickness or someone not coming on a shift there was asset procedure to follow to ensure that a replacement was found. Staff spoken with said that each shift worked as a good team each knowing what their responsibility was. There was work schedule near the lounge that detailed what staff must do on each shift and staff spoken with said that this worked well and it meant jobs always got done and they had time to spend with residents. Staff spoken with said that they felt competent to do their job staff were supported to access NVQ level 2 with some senior carers achieving NVQ level 3. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 21 Three staff files were viewed and were found to be well ordered and have an application form, two written references and the manager provided a matrix that showed that Criminal Records Bureau checks were sent and the reference number for each member of staff showing that the checks had been receive. The date the check was received was not on this matrix. The manager said that Criminal Records Bureau checks were stored separately at the head office and could be fetched quickly. However as the manager uses the matrix to provide key information it is recommended that the date received for the Criminal Records Bureau check and the Protection of Vulnerable Adults (POVA) First check is added to this form. Evidence was seen on staff files of a variety of training including all mandatory training such as first aid and moving and handling. Staff spoken with said that access to training was good and time was given to attend courses. Evidence was also seen of a thorough induction programme that covered information about policies and procedures as well as how to provide care to residents. This ensures new staff are supported and residents receive care from staff who are trained and competent to do so. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 22 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, 35, and 38 Quality in this outcome area is good. Residents’ benefit from living in a home that is well managed and run in their best interests. Their financial interests are safe guarded as well as their health safety and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has completed her Registered Managers Award and is awaiting the college to assess it. The manager was able to demonstrate ongoing training to update her knowledge and competences in managing the home. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 23 Staff spoken with were very positive about the manager and her ability to manage in the best interests of the residents. Evidence was seen that regular quality questionnaires are sent to relatives and residents, the most recent results are due to be published in the home’s news letter which is sent out at quarterly intervals. A copy of the newsletter is available in the reception area along with spare copies of the quality questionnaire. The provider was able to demonstrate the process of keeping himself up to date with what is happening within the home and receives regular bulletins from the manager regarding different aspects of the home. Regular meeting take place with the manager and the provider and other senior people within the organisation to ensure that improvements are made all the time. This is good practice. Records were well maintained to show that residents’ money was looked after appropriately protecting them from financial abuse. Records were seen showing that maintenance of the building ensuring it was safe for the residents and the staff. A new keypad system has been introduced to minimise the risk of residents with dementia wandering from the home. Those residents who are able to leave the building unescorted are still able to do so. Records were seen showing that fire drills and checks took place regularly and temperatures were taken regularly for the fridge, freezer and all hot food served in the home. Food was stored appropriately in the fridge with items labelled with date the item was opened. This minimises the risk of food poisoning within the home. All accidents were recorded with evidence that incidents were reported to the Commission. Records showed that staff were vigilant with any marks or sore area that were noted on residents person and records were maintained of action taken if required. This is good practice. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 7 Refer to Standard OP7 OP7 OP9 OP9 OP14 OP16 OP29 Good Practice Recommendations Include evidence of residents involvement in reviews Care plans could show more personal detail about individual residents needs. The drugs return book could be signed and dated by the staff representative in charge of this procedure. Copy of drugs error policy could be placed in a prominent position in the treatment room or attached to the Medication Administration Records. Residents could be informed more directly about advocate services. Where replies to complaints are stored on the individual residents files reference to this could be made in the complaints file. Add a column of ‘date received’ for the Criminal Records Bureau and for POVA First to the matrix currently used for staff records. Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Spencefield Grange DS0000064398.V321217.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!