Inspection on 30/04/07 for St Euphrasia`s

This inspection was carried out on 30th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Euphrasia`s 09/01/06

St Euphrasia`s 24/05/05

St Euphrasia`s 21/12/04

St Euphrasia`s 24/05/04

St Euphrasia`s 07/01/04

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 St Euphrasia`s Chain Road Blackley Manchester M9 6GN Lead Inspector Geraldine Blow Unannounced Inspection 30th April 2007 09:30 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 Euphrasia`s DS0000021659.V334206.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 Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Euphrasia`s Address Chain Road Blackley Manchester M9 6GN 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) 0161 653 2010 0161 653 8564 The Trustees of the Congregation of our Lady of Charity of the Good Shepherd Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of residents accommodated shall be 14 aged 65 years and over who are receiving care by reason of old age. Care will be provided to those who belong to the Good Shepherd order. 9th January 2006 Date of last inspection Brief Description of the Service: St Euphrasias is a purpose built single storey building situated in the extensive grounds of the convent with ample car parking facilities. The home is situated in Blackley in the North of the City and provides care for the older Sisters of the Good Shepherd. The home is close to local amenities and transport links into Manchester City Centre. Admission to the home is restricted to the Sisters who belong to the Order of The Good Shepherd. The home provides accommodation for up to 14 Sisters. Accommodation is offered in single bedrooms. Three bedrooms have en-suite facilities. A variety of bathing facilities are available. Toilets and bathrooms are located close to bedrooms and communal areas. There is a main lounge and a separate dining room. A conservatory is situated off the main lounge. The need for privacy and the facilities for prayer are important for the Sisters and a small chapel is available within the home, alternatively the Sisters can access the chapel in the convent via a corridor from the home. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 9 January 2006 and supporting information received in the Pre Inspection Questionnaire submitted by the home prior to this visit and the Annual Quality Assurance Assessment (AQAA) as well as 8 returned resident comment cards. This visit forms part of the overall inspection process and took place on Monday 30 April 2007. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This inspection was also used to decide how often the home needed to be visited to make sure that it meets the required standards. As part of the visit time was spent with the Sisters who live at the home, observing how staff work with the Sisters, discussions with staff and the home’s manager, assessing relevant documents and files and a tour of the premises was undertaken. Since the last inspection visit the homes conditions of registration have been changed. The home now only accommodates 1 Sister assessed as requiring nursing care and the home is staffed accordingly. The home does not intend to admit any further Sisters assessed as requiring nursing care. What the service does well: The home offered a clean and pleasant environment for the Sisters who live there and the atmosphere felt warm, welcoming and tranquil. One Sister said, “everything is perfect, couldn’t be better.” All received residents comment cards indicated that the home was always clean and fresh. One received comment was “very high standards of care and especially hygiene.” From observations made and from talking to staff and the Sisters the privacy and dignity of the Sisters was protected and they were encouraged to have choice with regard to their every day life. The staff were seen to be kind and patient with the Sisters and comments received in the comment cards were positive with regard to the staff. One comment was “I find the staff most helpful in every way” and “I am very happy and find the staff exceptional.” St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 6 The home carries out a pre admission assessment before a Sister is admitted to the home to make sure that the home can meet their assessed needs. Each Sister has a plan of care, which sets out how that care is to be delivered, and medication is given safely. A choice of meals was available at each mealtime and the staff said that any reasonable alternative to menu could be provided. The Sisters spoken to supported this. One comment card stated, “we are consulted about our meals and every effort is made to satisfy.” One Sister spoken to said, with regard to drinks and snacks that “we can have anything we ask for.” The home offered a variety of activities that was based on the requests of the Sisters and the received comment cards supported this. The home offered and encouraged training for staff to ensure that they had the necessary skills to meet the needs of the Sisters accommodated. Systems were in place to support the Sisters or visitors to make a complaint and this was confirmed by feedback given in the returned comment cards and the Sisters spoken to. What has improved since the last inspection? What they could do better: To prevent any possible risk to the Sisters the use of bed rails must be risk assessed before they are used. The manager and the nurse in charge said that regular audits of the medication administration system were undertaken but was not formally recorded. It is recommended that the audits be formally recorded to ensure the Sisters receive their medication as prescribed by the GP. In addition it is recommended that the home keep a copy of the GP’s original prescription to check against the MAR’s and items received from the pharmacy. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 7 A recommendation has been made regarding the recording of drinks that need to be thickened for one of the Sisters. 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. St Euphrasia`s DS0000021659.V334206.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 Euphrasia`s DS0000021659.V334206.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 (Standard 6 intermediate care is not provided at St.Euphrasia’s). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes an assessment of the Sisters care needs prior to their admission. EVIDENCE: The Sisters continue to have a pre-admission assessment of their needs prior to admission to ensure that the home can meet all of their assessed needs. For those Sisters referred through the Care Management arrangements, the home would obtain a summary of the Care Management Assessment prior to admission. The home does not provide an intermediate care service St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans of care were in place to ensure that the Sisters health and personal care needs were fully met and the systems and procedures for dealing with medicines appeared to protect the Sisters. EVIDENCE: Random samples of files were inspected, which included the Sister assessed as requiring nursing care. The manager said that the RGN’s oversee all the care plans, with particular reference to the nursing care plan. The files were well organised and maintained, and divided into relevant sections, which made them easy for staff to use as a daily working tool. The care plans clearly identified the needs of Sisters and the action to be taken by staff to ensure that all aspects of the health and personal care needs of the Sisters are met. The plans of care maintained the dignity and independence of the Sisters. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 11 Risk assessments had been included and the plans of care had been regularly reviewed to reflect changing needs and current objectives for health and personal care. However it was noted that the risk assessments relating to the use of bed rails did not address the risk of using the bed rail but only the risk of the Sister falling from the bed. The manager said that it was her intention, with input from the RGN’s, to review all the risk assessments to include more detail. Staff were observed delivering appropriate care and support to a number of the Sisters in the home and it was evident that staff had a good understanding of individual care needs. From observations made during the inspection visit, and from talking to the Sisters it appeared that the nurses and care staff treated the Sisters with respect and dignity. One Sister spoken to said, “ the staff are wonderful, they look after us very well and are very kind.” Each Sister is registered with a General Practitioner and evidence was seen of referral to other specialised services according to individual assessed needs for example District Nurses, Dentist, Dietician and Chiropodists. Medication Administration Record Sheets (MAR) were examined during this visit. There were no gaps in recording, with the exception of a drink thickener, details of which are described below, and all deliveries and returns of prescribed medications had been recorded. The manager and the nurse in charge confirmed that regular audits are undertaken to ensure that the Sisters are receiving their medication as prescribed. However these audits are not formally recorded. A recommendation has been made to address this. During a discussion with the manager and the nurse in charge they confirmed that 1 Sister was prescribed thickener, which is used to thicken drinks and soups for people with a swallowing impairment. There was not a recording of the number of thickened fluids given to the Sister. Following discussions, the manager agreed that all thickened fluids given to the Sister would be accurately recorded, along with the details of the recommended consistency given by the Speech and Language Therapist (SALT). The home employed 2 RGN’s and when on duty they had responsibility for medication administration. The care staff who also had the responsibility to administer medication had received training and further training had been arranged for 11 May 2007 from the local pharmacist, which included a 4-hour training session followed by an assessment of competency. To encourage and support the independence of the Sisters, where possible, they are encouraged to self-medicate. A risk assessment is undertaken to ensure the Sisters capability. Several of the Sisters were self-medicating and all rooms have a lockable storage space to ensure safe storage. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 12 The home did not have copies of the GP’s original prescription. In accordance with the Royal Pharmaceutical Guidelines and to maintian the safey of the Sisters it is reocmmended that the home should have a copy of the original prescription to check against the MAR’s and items delivered by the pharmacy. A recommendation has been made. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activities were provided and the Sisters were encouraged to exercise choice and control over their lives. Meals served at the home were nutritious, well balanced and offered a healthy and varied diet. EVIDENCE: The home operated an open visiting policy and visitors could be seen in the privacy of the Sisters own room or in any of the communal areas. The manager said that the Convent had facilities to accommodate visiting family if required. It was clear from observations and from talking to the Sisters that they were happy, relaxed and settled in their environment and there was a calm, happy atmosphere throughout this visit to the home. From observations and discussions with the manager and from talking to the Sisters that they were encouraged to exercise choice and control with regard to their day-to-day lives. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 14 The manager said that the Sisters were regularly consulted on a 1:1 basis regarding all aspects of their daily lives, which included activities and outings arranged on their behalf. In addition to this the manager held group meetings, which were minuted, on approximately a monthly basis or more frequently to keep the Sisters informed of ongoing issues, for example Province meetings or the new staff induction process. There was a list of daily activities on display, although the manager said that it was currently under review. It included activities such as daily Mass, exercise sessions, crosswords, DVD afternoons and in addition the Sisters, if they wish, go out for walks or are taken out for short trips. In addition 2 volunteers come into the home 1-day a week each. The manager said that both volunteers have had the appropriate safety checks. The response from all the received comment cards indicated that the Sisters were happy with the activities arranged by the home. The menu examined demonstrated that the home provided a varied diet, which was nutritionally balanced and included adequate supplies of fresh fruit and vegetables. The meal observed during the inspection visit looked and smelt appetising. The Sisters were seen to be enjoying their lunch, which was a chatty, social occasion and the Sisters spoken to were complimentary regarding the quality and quantity of food. The Sisters confirmed that drinks and snacks are provided throughout the day or night on request. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home encouraged and supported people to raise any concerns or complaints and had the policies, procedures and systems in place to protect residents from abuse. EVIDENCE: The home had a complaints procedure in place. The Commission for Social care Inspection had not received any complaints about this service and the manager informed the inspector that the home had not received any complaints. She was aware of the need to keep a record of all complaints made and include details of the investigation and any action taken. The manager appeared to have a high profile within the home and made herself available to the Sisters. She said that she operated an open door policy and encouraged people to raise any concerns or complaints. The Sisters spoken to said that they had never wanted to make a complaint but would go to the manager or any of the staff and felt that their complaint would be taken seriously. All returned comment cards indicated that the Sisters knew who to speak to if they were not happy. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 16 Evidence was seen that staff had attended Protection of Vulnerable Adults training (POVA) and the manager said that further training was to be provided to ensure that all staff employed receive the training. The home had policies relating to the Protection of Vulnerable Adults from Abuse and had a copy of the Manchester Multi-Agency Policy on the Protection of Vulnerable Adults from Abuse “No Secrets” Guidance. The manager was able to describe the action to be taken in the event of an allegation of abuse being made. St Euphrasia`s DS0000021659.V334206.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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A clean comfortable, well maintained environment was provided for the Sisters. EVIDENCE: The home felt comfortable, relaxing and homely. All areas of the home were tastefully decorated and furniture was of a domestic nature. Evidence was seen of regular ongoing maintenance and renewal of the fabric and decoration. The home was exceptionally clean, tidy and free from offensive odour. All the returned comment cards indicated that the home is always fresh and clean. One comment received stated, “the home is well provided with cleaners, all of whom take an interest in their work.” As already stated in this report the need for privacy and the facilities for prayer are important for the Sisters and a small chapel is available within the home, St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 18 alternatively the Sisters can access the chapel in the convent via a corridor from the home. An enclosed courtyard is available for the Sisters to sit in or walk around and the Sisters have access, via the conservatory, to an attractive patio area and the convent’s extensive and well-maintained gardens. The home had ample bathing and toilet facilities to meet the needs of the Sisters accommodated. Bathrooms/sluice rooms and toilets were all clearly marked. The bathrooms and toilets were found to be clean and equipped with the necessary aids and equipment to assist in the bathing of the Sisters. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff available appeared sufficient to meet the Sisters assessed needs and the home’s recruitment and selection process provides protection for the Sisters from potential abuse. EVIDENCE: At the time of this visit the home accommodated 14 Sisters. From observation during the inspection the numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of Sisters accommodated. The home employed 10 care staff, 5 of which had achieved NVQ level 2 or above, 1 member of care staff was currently undertaking NVQ Level 2 and a further 2 members of care staff had been registered to undertake it. Due to the homes conditions of registration being changed and the home only accommodating 1 sister assed as requiring nursing care a number of new care staff and 2 RGN’s had recently been recruited. A small number of staff files were examined. Evidence was seen of a completed application form, 2 written references, one of which was from the last employer. In addition the manager said that is some cases she obtains a telephone reference that is then St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 20 supported by the written reference. Copies of certificates were seen and the manager said that photographs for the new staff were in the process of being developed. Evidence was seen that CRB’s had been applied for, for all newly appointed staff, however, due to a misunderstanding, some staff had commenced employment without a POVA First or a clear CRB being obtained. This was discussed at length with the manager and the Sister responsible for submitting the CRB applications to the homes Counter Signatory in London. The staff were immediately taken off duty and the day after the inspection visit the manager said that she had received confirmation that the POVA Firsts would be available within 48h hours and until they had been received those staff would remain off duty. Staff had an individual training and development programme, which included an annual appraisal where training needs were identified and discussed. Evidence was seen of ongoing staff training, which included NVQ 3, Communication Training, Manual Handling Training, Food Hygiene, Safe Handling of Medication, POVA and End of Life Care. The manager said that staff are encouraged and support to undertake training. The manager said that all newly recruited members of staff must complete the Induction day, an Induction shift and a Structured Induction Training Programme. Evidence was seen that the Sisters had been involved in the new staff orientation day. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home operates in the best interests of the Sisters EVIDENCE: Since the last inspection the registered manager retired and a new manager took up post on 1 April 2007. The manager has worked as the Business Manager for St Euphrasia’s and has worked closely with the previous registered manager. She is in the process of applying to undertake the Registered Manager Award and has applied to the Commission for Registration. Evidence was provided that the home had appropriate service contracts in place for equipment and installations used in the home and that servicing is undertaken at the required intervals to ensure the safely of residents. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 22 Where possible the Sisters have control of their own money. For the Sisters who are unable to do this a liaison Sister from the convent has this responsibility. Records and receipts are kept of all transactions. To ensure the Sisters are happy with the quality of care being provided daily discussions are held with all Sisters and as part of these discussions they are encouraged to discuss the quality of care provided and raise any concerns they may have. There is also group meeting undertaken with the Sisters, approximately on a monthly basis. In addition there is a monthly Trustee unannounced visit to the home where all the Sisters are spoken to. To further quality assure the service the manager said that it was her intention, later in the year, to develop and send out questionnaires to visiting professionals to the home to gain their view of the service being provided. . St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 3 3 x x x x x x 4 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 4 x 3 x x 3 St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13 (4) (c) Requirement To ensure the health and safety of residents risk assessments relating to the use bed rails must be reviewed and further developed to adequately assess the risk of the actual use of the bed rail. Timescale for action 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations 1. It is recommended that the MAR should clearly cross reference to where there is a signed accurate recording of thickened fluids given to the Sister. 2. It is recommended that the home keep a copy of the GP’s original prescription to check against the MAR’s and items received from the pharmacy. 3. It is recommended that the informal medication audits be formally recorded to ensure the Sisters receive their medication as prescribed by the GP. St Euphrasia`s DS0000021659.V334206.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North West Regional Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU 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 Euphrasia`s DS0000021659.V334206.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. 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!