Inspection on 08/07/05 for The Heathway

This inspection was carried out on 8th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Heathway 17/07/06

The Heathway 30/11/05

The Heathway 02/12/04

The Heathway 03/08/04

The Heathway 22/10/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Heathway 70 Reddicap Heath Road Sutton Coldfield West Midlands B75 7EN Lead Inspector Kulwant Ghuman Unannounced 28th June 2005 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 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. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Heathway Address 70 Reddicap Heath Road, Sutton Coldfield B75 7EN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 329 2222 0121 378 1878 Birmingham City Council Indira L Surju Care Home 26 Category(ies) of Old Age (26) registration, with number of places The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered to accommodate 26 adults over the age of 65 who are in need of care for reasons of old age and may include mild dementia 2. That minimum staffing levels are maintained at 4 care assistants plus a senior member of staff throughout the waking day of 14.5 hours 3. Additionally to the above minimum staffing levels, there must be 2 waking night care staff and a senior on waking or sleeping-in duty 4. Care manager hours and ancillary staff should be provided in addition to care staff 5. Registration category will be 26 (OP) Date of last inspection 3rd December 2004 Brief Description of the Service: The Heathway is a large, purpose built Local Authority care home for 26 elderly people. The home is located in Sutton Coldfield in a mainly residential area close to the Falcon Lodge estate. Sutton Coldfield centre is approximately one mile away where numerous community facilities are located. Public transport is available from outside the home. The building comprises of three floors but living accommodation for the residnets is provided on the first and second floors. The ground floor provides office space for the management of the home together with an age concern coordinator, community psychiatric nurses and a day centre. Also on the ground floor is the main kitchen and laundry. The two upper floors are a mirror image of each other in design and comprise of two lounges, a dining room, bedrooms and small kitchenettes. There are bathing and toilet facilities throughout. The residential accommodation for the residents was generally well decorated and comfortable. A sensitivity garden with ramped access, smooth brick surfaces and raised flowerbeds is at the rear of the home and provides residents with a pleasant, sheltered environment in which they and day centre users can enjoy the warmer weather. There is parking to the front and side of the home. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector over part of the day in June 2005 and was the first of the two statutory visits of 2005/2006. During the inspection the communal areas of the home were inspected, two resident files and one staff file was sampled as were a number of other care documents. The inspector spoke to two residents in depth and 4 residents briefly. One member of staff was spoken with along with the manager and two assistant managers. What the service does well: 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 Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 The information available to the residents and their representatives was not current and accurate and needed to be amended so that residents are able to make an informed decision. The home does not always have adequate information available to them at the point of admission of the resident to ensure that their needs can be met. EVIDENCE: The changes identified as needing to be made to the statement of purpose at the last inspection had not been made. Residents were given a copy of the service users guide but this information was not all correct. Of the two resident files sampled one resident had received a residential care agreement but the other had not. The rooms to be occupied by the residents were identified on the files however, the fees to be paid were not. Where residents were admitted to the home on a short term or temporary basis they were less likely to receive a residential care agreement. This issue had been raised at earlier inspections. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 8 The manager confirmed that the care plans and assessments received from the social worker on one of the files sampled were not received until two months after the resident had been admitted to the home. Both the residents and their representatives were able to visit the home prior to deciding whether to move into the home. The pre-admission visit to the home provided very little information about the residents’ needs apart from the fact that they ate and drank well and enjoyed chatting to the other residents. It is difficult to see therefore, on what basis the home made the decision to admit the residents. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The care planning processes and risk assessments were not individualised or detailed enough to enable residents’ needs to be met. The management of medication and administration was good ensuring that residents received their medicines in the manner prescribed. Some improvements could be made in respect of promoting privacy for residents. EVIDENCE: Of the two residents files sampled neither had an adequate individual service statement (ISS) available to guide staff on how their needs were to be met. Even where residents were admitted to the home on a temporary or short term basis an ISS needed to be formulated from the information collected. This information could be collected from the placing authority’s assessment, observations made at the pre-admission visit and those involved in the care of the resident before admission to the home. The ISS could be further developed following the trial period of 4 weeks at the home, however, this would only be possible if care staff make accurate and detailed recordings about the type of care provided by them, the tasks the individual could carry out themselves and observations about likes and dislikes. The care needs of the residents needed to be reviewed on a monthly basis. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 10 Residents health care needs were being adequately met. There were visits from the district nurses to attend residents who required injections and dressings. There were visits from the GP and hospital appointments were attended as required. The home was experiencing some difficulties regarding the meeting of a residents medication and health requirements. A multidisciplinary meeting was due to be held during the day of the inspection. The chiropodist visited on a regular basis and the inspector was told by the manager that the chiropodist attended to residents either in the bathroom or their bedroom. There were manual handling assessments and general risk assessments in place on the files sampled however, one of the manual handling assessments did not identify the sling size to be used in the event of a fall. In the case of the other resident it was not possible to identify from the ISS or manual handling assessment that the individual used a walking stick in the home, that the resident needed to sit with legs elevated and the reason for this. There were no nutritional and tissue viability assessments in place on the files sampled. The home used the Nomad system of medication administration and there were documented checks on a weekly basis carried out on the administration of medication leading to a system that was well managed that ensured that residents received their medication as directed. There was a risk assessment in place for the resident who was managing his own medicines and the staff checked that he was taking them as they were responsible for re-ordering of medicines. It was recommended that regular checks were made by the staff to ensure that he continued to take the medication as directed and that these checks were documented. There were locks on bedroom doors and keys were held by some residents however, one resident stated that a key had not been made available and felt that one should have been offered on arrival. The inspector was also told about an incident where a member of staff had entered the bedroom and the resident had felt quite afraid. Staff must ensure that doors are knocked before entering bedrooms and knocks are loud enough to be heard by residents who may be hard of hearing. An issue was raised in a residents meeting regarding the fact that residents had to go to the ground floor to use the public phone. The home needed to look into making a portable phone available to residents on the floors that they lived. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Residents were afforded a lifestyle that met their needs, maintained contact with family and friends and provided choices and nutritious food at mealtimes. EVIDENCE: The residents spoken to said that they were very satisfied with the life that they had and said that there were no rigid rules in the home. Residents were seen to be sitting in the lounges, moving around between lounges or returning to their bedrooms if they wished. Residents were seen to be well cared for with many of the female residents wearing make–up, nail varnish and jewellery. One resident got changed after dinner as was her daily routine. There was evidence that residents could attend church services in the conference room, on the ground floor, that had been recently re-decorated. There were in-house activities in the home on a regular basis including bulls eye, bingo, card games, exercises, sing a longs and films. Some residents went out with relatives on a regular basis. Residents’ visitors were welcome at the home and could sit with residents in the lounges or their bedrooms. There were regular meals provided in the home that were varied and nutritious and provided for choices at all meal times. There was a four week rolling The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 12 menu and residents said that they were asked the day before what they wanted. Meals were provided in a comfortable setting. The inspector was informed that due to the number of residents with Zimmer frames these had to be removed from the dining room whilst meals were eaten due to health and safety. The manager was reminded that the Zimmer frame needed to be made available as soon as the resident wanted it otherwise it could become a form of restraint. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 There was an appropriate complaints procedure on site and residents received a copy of this in the service users guide. There was an adult protection procedure in place and this was followed to ensure the safety of residents when required. EVIDENCE: There was a complaints procedure available to residents and a copy was seen in the service user guide. The residents were reminded about making use of the complaints procedure at a residents meeting. The procedure referred to the NCSC and needed to be updated. There had been one complaint made directly to the home which was being investigated by another manager. Following completion of the investigation the manager needed to ensure that the complaint was logged in the home with details of the investigation and outcomes arrived at. There was an adequate adult protection policy in the home. There had been one adult protection raised by a relative however, the resident moved to another home and the investigation concluded. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,25,26 Residents lived in a comfortable, homely and safe environment with adaptations in place to meet the needs of the residents. The home was clean and odour free. EVIDENCE: The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 15 The location and layout of the home were suitable for its stated purpose. It was accessible, comfortable and generally well maintained with only minor issues of décor being raised during the inspection that the manager would need to address over time. The corridors within the home were in need of replacement flooring as they were tiled and had worn over the years and detracted from the homely nature of the home. There was a central courtyard that residents could access during the warm weather. There was a variety of lounges that residents could sit in and all were comfortably furnished and homely. There were adequate numbers of toilet and bathing facilities in the home. There was a small bathroom on the first floor that was not suitable for residents who needed assistance. There were two other bathrooms on this floor, including one that had a walk-in shower. On the second floor there were two suitable baths and one walk-in shower. Residents had access to all areas of the home via ramps and a passenger lift. There were hand rails along corridors and grab rails in bathrooms and toilets. Hoists were available for those residents who needed them. There was a new emergency call system throughout the home for the residents use. Storage of laundry trolleys and wheelchairs was a problem and they had to be stored in bathrooms/shower rooms. There was central heating throughout the home. All radiators had been guarded however, the type of guard installed meant that residents were not able to control the level of heating in their rooms. Hot water was available throughout the home. Window openings in bedrooms were not accessible to residents. There was still some fluorescent lighting in the home that should be replaced with more domestic type lighting. The premises were found to be clean and free from offensive odours throughout however, the underneath of one of the bath hoists needed to be cleaned and this was done immediately. There were systems in place to control the spread of infection. Staff were observed to be wearing the appropriate protective garments. The laundry was fully equipped with a sluice washing machine and two new tumble driers. The flooring in the laundry had been replaced. The kitchen was well organised and clean. There was a commode pot washer in the home. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 Adequate staffing levels were being maintained at the home enabling the needs of the residents to be met. The home needed to increase the number of staff employed so that continuity of care could be given to the residents. EVIDENCE: The home continued to experience difficulties in recruiting staff. The inspector was informed that the home had over 200 care staff hours vacant. There were a large number of casual and agency staff being used to ensure that there were adequate numbers of staff on duty. The home managed to achieve the required staffing levels by the use of casual and agency staff. The manager raised the issue of some of the agency staff not undertaking some of the duty required of. Some of the residents commented to the inspector that the staff did not talk to them much and issues were raised in the residents meeting about the agency staff. The manager was recruiting some staff and it was hoped that some of the issues would be resolved. One staff file was sampled and this evidenced that a thorough recruitment procedure was followed by the home. The manager needed to check the authenticity of the references received as one of the references was dated 2002 and referred to the member of staff having worked at the previous place of employment for 4 years whereas the application form indicated that the employment had lasted 7 years. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,38 The manager ensured the smooth running of the home in a competent manner. The health and safety of the residents and staff was very well managed. EVIDENCE: The manager was appropriately qualified and experienced and ensured that the needs of the residents was the focus of activity in the home and the home was being managed in an open and appropriate manner. There had not been regular staff meetings due to the shortages of staff however the manager informed the inspector that important issues were discussed at handovers. There had been one residents meeting this year. There were a few issues regarding the management of health and safety in the home that were raised during the inspection including the fact that some of the emergency lighting batteries in the home had been removed for approximately The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 18 12 weeks and replacements had not been received meaning that monthly emergency lighting tests were not being adequately carried out. Fridge temperatures needed to be recorded on a daily basis in the unit kitchens. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 2 x 3 2 2 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 3 x x x x 2 2 The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 20 Yes Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 4(1) Sch 1 Requirement The registered person must ensure that the statement of purpose is accurate and all appendices are available. A copy of the updated statement of purpose must be forwarded to the CSCI. (Previous timescale of 18.1.04 not met) The registered person must ensure that the service users are given a contract reflecting their status in the home. (Previous timescale of 1.10.04 not met) All residents must be given a contract or terms and conditionsof residence at the point of entering the home. A copy of the assessment of the residents needs must be received by the home prior to the admission except in the case of an emergency. There must be a record of the care homes charges to the resident. The registered person must ensure that a recorded assessment is carried out at the pre-admission visit. (Previous timescale given of 1.3.05 not met.) Timescale for action 1.9.05 2. OP2 5(1) 1.8.05 3. OP2 5(1) 1.8.05 4. OP3 14(1)(b) 1.8.05 5. 6. OP3 OP5 17(2) Sch4(8) 14(1) 1.8.05 1.8.05 The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 21 7. OP7 15(1) 8. OP7 12(1)(a) 9. OP7 15(2)(b) 10. 11. OP7 OP10 13(5) 12(4)(a) The registered person must ensure that ISS’s cover all the identified needs of service users and state how these will be met by care staff. (Previous timescale of 1.10.04 not met) The registered person must ensure that the service user assessment covers nutritional needs and tissue viability. (Previous timescale of 18.1.04 not met) The registered person must ensure that the ISS is reviewed on a monthly basis by care staff and any changes in need must be reflected in the ISS. (Previous timescale of 1.10.04 not met) The moving and handling assessments must include all relevant information. All residents must be offered keys to their bedrooms on admission. Staff must ensure that doors are knocked before entering bedrooms. The home must look at ways in which residents can be enabled to make telephone calls in private. The registered person must ensure that there is a record of all complaints made to the home and the actions taken in relation to the complaint. (Previous timescale of 1.3.05 not met.) Flooring in the corridors should be replaced. (Previous timescale of 18.3.04 not met) Lighting throughout the home should be domestic in character.(Previous timescale of 1.5.04 not met) The registered person must ensure that service users are 1.9.05 1.9.05 1.9.05 1.9.05 1.8.05 1.8.05 1.10.05 12. OP10 12(4)(a) 13. OP16 17(2) Sch4(11) 1.9.05 14. 15. OP19 OP25 23(2)(b) 23(2)(p) 1.10.05 1.10.05 16. OP25 23(2)(p) 1.10.05 Page 22 The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 17. OP25 23(2)(p) 18. 19. OP26 OP29 13(3) 17(2) Sch4(6) 24(1) 26(5) 20. 21. OP32 OP37 22. OP37 12(3) 23. OP38 23(2)(c) able to control the temperature of radiators in their bedrooms. (Previous timescale of 1.10.04 not met) Window openings in all bedrooms must be accessible to residents. (Previous timescale of 1.6.05 not met.) Unit fridge temperatures must be recorded on a daily basis. The registered manager must check the recruitment documents for any discrepancies. The manager must ensure that regular staff meetings are held. The registered person must ensure that reports of the monthly team managers visits are available for inspection. (Previous timescale given 1.2.05. Compliance not checked at this visit.) The registered person must ensure that service user meetings are held on a regular basis. (Previous timescale of 1.1.05 not met.) The emergency lighting batteries must be replaced. 1.10.05 29.06.05 1.9.05 1.9.05 1.9.05 1.9.05 1.8.05 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. Refer to Standard OP9 OP16 Good Practice Recommendations Staff should carry out occasional checks to ensure that residents managing their own medicines continue to be able to do so. The complaints leaflet should be updated to refer to the CSCI. The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 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 The Heathway E54_S33584_TheHeathway_V235842_ 280605 Stage 4.doc Version 1.40 Page 24 - 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!