Inspection on 10/01/07 for St Audrey`s

This inspection was carried out on 10th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

St Audrey`s 14/02/06

St Audrey`s 14/09/05

St Audrey`s 22/11/04

St Audrey`s 08/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Audreys 15 Church Street Hatfield Hertfordshire AL9 5AR Lead Inspector Claire Farrier Unannounced Inspection 10:00 10 January to 22 January 2007 th nd 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 St Audreys DS0000019535.V327726.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. St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Audreys Address 15 Church Street Hatfield Hertfordshire AL9 5AR 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) 01707 272264 01707 258243 Lynn.Beech@HeritageCare.co.uk www.heritagecare.co.uk Heritage Care Mrs Lynn Beech Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: St Audrey’s is a large Victorian house that was extended and refurbished in 1996 to provide a care home for 38 elderly people. The home, which is run by Heritage Care, is situated in Old Hatfield and is part of the Hatfield House Estate. The house is close to the amenities of the local shops and the town centre. The main railway station is near by and the area is well served by public transport and major roads. The home is very well appointed and stands in spacious grounds with attractive rural views from many rooms. Accommodation is provided in single bedrooms most of which have en-suite facilities and are sufficiently large to be comfortable bed sitting rooms. St Audrey’s offers a high standard of residential care for those residents who still value their independence and wish to be comfortable in a caring and safe environment. The home was first registered with the Local Authority Inspection Unit on 30th July 1996 under the Registered Homes Act. The Statement of Purpose and Service Users Guide provide information about the home for referring social workers and prospective clients. The current charges range from £400.24 to £565.31 per week. St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day. Following the inspection visit to the home, an allegation was made by the relative of a resident in the home. The period of inspection was extended in order to include the results of this investigation (see Complaints and Protection). The focus of this inspection was to assess all the key standards. Some additional standards were also assessed. The majority of time was spent talking to residents and staff, and discussions were held with the home’s manager. Some time was also spent looking at records, care plans and staff files, and the inspector made a tour of the premises. What the service does well: All the residents who took part in the inspection are happy in the home. They said that they receive a good quality of care in the home, and the staff treat them well. One resident said, “ The staff are excellent. They will always help when asked. They are very caring.” Another commented that everything is good here. A visitor said, “There is a lovely atmosphere in the home. The staff are very caring. They are always available to answer any questions.” The residents were particularly complimentary about the meals served in the home. All the food served in the home is home made from fresh ingredients, including soups and cakes, and there is a good choice of meals. There is a stable staff team in the home, and the training programme ensures that they have the necessary skills to meet the residents’ needs. All the care staff have NVQ qualifications, or will start to take them as soon as their induction training is completed. The staff spoken to were enthusiastic about their work, and said that a good quality of training is provided for them. The staff were observed to have a good relationship with the residents and to treat them with a friendly respect. They have time to talk to them and to provide the care they need without rushing. Health care in the home is particularly notable. The home has a good relationship with all the local GPs and community nurses, and a visiting GP commented that the home provides a good quality of health care, and he is confident of their abilities. Evidence was seen that the home is proactive in promoting good health. The home has a welcoming and sociable atmosphere. The ethos of Heritage Care is that residents’ views are valued, and they are actively involved in the running of the home. At St Audrey’s the residents said that feel involved and they are consulted about their lives in the home. They take part in activities that are designed for their individual interests. The care plans are written with St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 6 an emphasis on assisting and enabling the residents to be as independent as possible. The quality assurance system is commendable. It is based on the views of the residents and forms the foundation of the service, leading to a cycle of planning, action and review for developing the services provided by the home. Residents take part in staff recruitment, and sit on the interviewing panels. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. St Audreys DS0000019535.V327726.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 St Audreys DS0000019535.V327726.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 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive assessment of the needs of the residents was seen to be in place, and appropriate risk assessments are carried out to ensure that the residents live in a safe environment. The home has sufficient information on residents’ needs and access to appropriate services to enable the needs to be met. EVIDENCE: The files of three residents were inspected, and each one contained a full assessment that was completed before the resident was admitted to the home. The assessment format has a dependency score for each part, and details of the person’s needs. The total scores show whether the person has a low, medium or high level of dependency. Care plans are written from the information in the assessments, and the assessments and care plans provide appropriate information so that the staff can meet each person’s needs. The assessments include a risk assessment for moving and handling. St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 10 Staff members were observed to have a good relationship with the residents. They have the skills and experience to meet the residents’ care needs. The home has an ethos that puts each resident at the centre of the care that is provided for them. The residents who were spoken to during the inspection were all very happy in the home, and enjoyed the sociable atmosphere. One person had been in the home for only two weeks, and had already decided that she wanted to remain there permanently. St Audreys DS0000019535.V327726.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 excellent. This judgement has been made using available evidence including a visit to this service. Detailed care plans are in place for all the residents, and they provide clearly written information on each person’s individual needs, which ensures that all their needs are identified and can be met. The home monitors and addresses all the residents’ health needs, and is proactive in addressing any possible health needs. The home has good procedures for the administration and recording of medication. The residents said that staff treat them with respect, and the policies and practice in the home also promote privacy and dignity for the residents. St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 12 EVIDENCE: Detailed case tracking was carried out through the files of three residents. They contain clear and easily accessible information on the resident’s health and personal care needs, with comprehensive procedures for meeting the needs. The care plans are written in a person centred way, which puts each resident at the centre of all decisions involving their care. The process takes individual needs and views fully into account, and encourages the residents to be as independent as possible and in control of their daily lives. The assessments carried out before a resident is admitted to the home contain action points that are then included in each care plan. These include assisting each resident with their personal hygiene and supporting them to improve incontinence. Each care plan typically includes the words “support X to improve” or “support X to maintain.” Each resident, or a member of their family, completes a life history when they are admitted to the home, and the staff spoken to showed that they know and treat each person as an individual. All the residents spoken to said that the staff treat them with respect. The care plans contain good information on the residents’ health care needs, with appropriate monitoring of specific health concerns and recording of all contacts with medical practitioners. The residents can choose their own GP, and four local surgeries provide health care for the home. The home has a good relationship with all the local GPs and community nurses, and both were in the home during this inspection. The GP commented that the home provides a good quality of health care, and he is confident of their abilities. Evidence was seen that the home is proactive in promoting good health. If there is any indication that a resident may have a urinary tract infection, the staff take a urine simple to the GP surgery, and any necessary treatment can be started immediately. The home has good procedures for the administration and recording of medication. The senior staff currently administer the medication, and training has been arranged for all the care staff. Residents are able to look after their own medication if they wish to, and they sign their MAR (medication administration record) chart when they receive their supply of medication. The MAR charts contain appropriate information that should be noted, for example that one person should not be given grapefruit because of a medication they have. The MAR chart also states which medications are in blister packs, and where in the trolley the medications that are not in blister packs are stored. There is good information on when PRN (when required) medications, such as paracetamol, should be administered for each person, and the staff also record if paracetamol was offered and refused. Controlled medications are stored and recorded appropriately, but the name of the supplying pharmacist is not recorded in the register. St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 13 The home keeps minimum stocks of medication in the home, and those not currently in use are stored in a room on the top floor. Following the last inspection a thermometer has been placed in this room, but the temperature is not recorded and monitored regularly. The temperature of the storage room on the day was 21°C, but some of the bottles of lactulose indicated that they should be stored at below 20°C. The contents of some of these bottles were changing colour, which may be an indication of deterioration due to a high temperature. The medication trolleys are stored in the dining room. The temperature there was measured during the inspection, and it was seen to be below the maximum recommended temperature. However this inspection took place on a cold January day, and the temperature should be monitored and recorded regularly to ensure that there is no risk of deterioration. Medication should always be stored in accordance with the manufacturer’s instructions so as to ensure its effectiveness. St Audreys DS0000019535.V327726.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. This judgement has been made using available evidence including a visit to this service. Maintaining contact with families and friends is promoted by staff in accordance with the residents’ wishes. The residents enjoy wholesome and varied meals, which provide a well-balanced nutritious diet. Residents maintain their independence by making choices about the food and how they spend their days. EVIDENCE: There are regular residents meetings in the home, and the residents spoken to confirmed that they are consulted about their lives in the home. There is no formal activity programme in the home. Some residents said that they prefer more individually organised activities, and this is in keeping with the person centred ethos of the home. Each person’s care plan has details of their interests, and a care plan for activities that they would like to do. The key workers are responsible for ensuring that the residents are able to take part in the activities that they enjoy, which may include playing Bridge or Connect 4. The activities co-ordinator arranges some group activities that the residents enjoy, such as carpet bowls. A reflexologist visits the home once a week and provides hand and neck massages. There is a sociable atmosphere in the home, and small groups of residents were seen sitting together and talking to St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 15 each other. One person said that she particularly likes the home because the other residents are friendly and sociable. Families and friends are welcomed into the home, and family members are consulted about the resident’s care. Two visitors were spoken to during this inspection. One said that she feels very welcome in the home. The other visits every day, and said that she is kept informed about her mother, and the staff are always available to answer any questions. The inspector had lunch with the residents, and enjoyed both the food and the sociable atmosphere. The chef consults the residents about what they would like, and due to their popularity there are two roast dinners every week. All the food served in the home is home made from fresh ingredients, including soups and cakes. There is a choice of main dish every day, and soup, omelettes and salad are always available. There are themed days in the home on special occasions, such as Valentines Day and Halloween, when the dining room is decorated and a special menu is served. Several residents said how enjoyable the Christmas Day dinner was. Pureed meals are available for residents who have difficulty in chewing and swallowing food, and one resident has a pureed meal by choice. The Environmental Health Officer carried out an inspection of the kitchen two weeks before this inspection, and made no requirements. St Audreys DS0000019535.V327726.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. This judgement has been made using available evidence including a visit to this service. The home has a comprehensive complaints procedure in place, and residents and their relatives are confident that any complaints will be properly investigated. All staff have appropriate training on prevention of abuse, and robust polices and procedures are in place to ensure that the residents are protected. EVIDENCE: The home has a satisfactory complaints procedure in place. Residents and their relatives are encouraged to make their concerns and complaints known. One complaint has been recorded since the last inspection. This was investigated appropriately, and changes were made as a result. The complaints record contains details of the complaint and the investigation, but there is no space for the outcome of the complaint. This should include whether the complainant was satisfied, and any actions taken as a result. All the staff have training in the prevention of abuse. The staff spoken to are aware of the home’s procedures and of the whistle blowing policy. Following the inspection visit to the home, an allegation was made by the relative of a resident in the home. It was investigated by Social Services, and the police were informed. No evidence of misdemeanour found. St Audreys DS0000019535.V327726.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and gardens are well maintained and provide a comfortable and attractive environment for the residents. Individual and communal facilities are appropriate for the residents’ needs. This ensures that the residents are able to maximise their independence and live in a safe and comfortable environment. EVIDENCE: St Audrey’s is a large detached Victorian House, situated in the village of Old Hatfield. The house is surrounded by well kept gardens, which adjoin the grounds of Hatfield House. The house is comfortable furnished and well maintained. Many of the bedrooms are large, and all have an individual character. The home appeared to be clean throughout, and there were no offensive odours. Appropriate procedures are in place for the control of hygiene. St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 18 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 group is good. This judgement has been made using available evidence including a visit to the service. Staff numbers in the home are sufficient to ensure that all the residents’ needs are met, and staff receive appropriate training. Good recruitment procedures and staff training make sure that, as far as possible, the residents are supported and protected in the home. EVIDENCE: The home continues to retain a core group of experienced and well trained staff who are able to offer continuity of care for the residents. Many of these carers have worked at the home for many years. During this inspection the staff all appeared to be enthusiastic about their work and to take great pride in the service and in the home. They were seen to work well together as a team and to work meeting the residents needs in a competent manner. All residents questioned confirmed that they were happy with the manner in which care was given to them. “ The staff are excellent. They will always help when asked. They are very caring”, one resident told the inspector. The home has a good level of staffing, with five care assistants and a team leader during the morning, and four care assistants and a team leader during the afternoon. At night there are two care assistants on duty in the home, and a care team leader sleeps in to provide support if needed. Agency staff are only used in an St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 19 emergency, and then they are usually staff who have worked in the home before and know the residents. The numbers of staff holding professional qualifications, NVQ s at levels two and three considerably exceeds the requirement for 50 . All the care staff have either already completed the qualification, or are currently studying for it. The staff spoken to confirmed that there is a lot of training available, and the courses are very good. Two new members of staff were completing their induction training, and they said that they would then start the NVQ course. The home’s own records showed that a yearly plan is made up from the individual training requirements of each member of staff, which core retraining planned on an annual basis. The files of three members of staff who have recently started to work in the home were inspected. They showed evidence of a thorough recruitment procedure, including comprehensive application forms, references and notes of the interviews. Some of the residents take part in recruitment of staff, and sit on the interview panels. It was reported that there is a quarterly audit of all files to ensure that they contain all the required information about the staff working in the home, but some of the required evidence that a person is fit to work in the home was not seen in these files. (See Management and Administration.) St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 20 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, 34, 35, 37 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed. The management actively seeks the views of the residents and other involved people in order to ensure that a good quality of care is provided. Adequate records are maintained for the effective management of the home and monitoring of heath and safety procedures. EVIDENCE: The manager has many years experience in care and management. She has health and social care qualifications, and she intends to complete the Registered Managers Award (RMA) within the next year. St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 21 The home has a sound quality assurance system in place that meets the needs of the service. Heritage Care has devised a Care Pathways audit, with its own standards for the quality of care provision in the home. Four of the standards are audited each year, and the managers of Heritage Care homes audit each other’s homes. The audit includes a visit to the home, questionnaires for the residents, and discussions with the residents. The outcomes of the audit are incorporated into the annual business plan for the home. The business plan for St Audrey’s for 2006 to 2007 was seen. It takes into account expected maintenance and replacement of equipment and furnishings, such as the boilers in the home, the carpets in the lounge, and hoists and baths. Seven objectives were set from the results of the last quality assurance audit, and the business plan contains the measures to be taken for each, and how they will be monitored. The objectives for this year include access to the Internet for the residents, and IT training for the staff. Together with the monthly monitoring visits that the company carries out in the home, this procedure provides a robust and commendable system for monitoring the quality of care in the home. It is based on the views of the residents and forms the foundation of the service, leading to a cycle of planning, action and review for developing the services provided by the home. The arrangements for management of residents’ money were inspected and appeared to be accurate. Money is stored safely and adequate records are maintained in order to protect service users from financial abuse. The home maintains appropriate records for the health and safety of the residents and staff in the home, and staff follow the home’s policies and procedures. No health and safety concerns were observed during this inspection. However the staff files that were seen on this occasion do not contain some of the required evidence that a person is fit to work in the home. (See Staffing.) It was reported that there is a quarterly audit of all files to ensure that they contain all the required information about the staff working in the home, but there was no evidence of a satisfactory CRB (Criminal Record Bureau) check, or of a confirmation of good health. None of the files seen contained a recent photograph. St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 22 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 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 4 X 3 X 2 3 St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 23 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 OP37 Regulation 17(2) Requirement The staff files seen did not contain satisfactory evidence of the fitness of the person to work in the home. All the required information on staff, as listed in Schedule 2 and Schedule 4(6) of the regulations, must be kept in the home, including, confirmation of the person’s health, evidence of satisfactory CRB checks and a recent photograph. Timescale for action 31/03/07 St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 24 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. Refer to Standard OP9 Good Practice Recommendations The temperatures of areas used to store medication were satisfactory on the day of the inspection, but they are not monitored. It is recommended that the temperatures of all areas used to store medication are recorded regularly and monitored to ensure that they do not rise above 25°C, in order to prevent the risk of administering medication that has deteriorated and is no longer effective. It is recommended that the controlled drugs register should contain a record of the name of the supplying pharmacist. There is no space on the complaints record for the outcome of the complaint. The record of complaints should include the outcome of the complaint, whether the complainant was satisfied, and any actions taken as a result. 2. 3. OP9 OP16 St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Herts Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 St Audreys DS0000019535.V327726.R01.S.doc Version 5.2 Page 26 - 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. 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