Inspection on 30/11/07 for The Hollies

This inspection was carried out on 30th November 2007.

CSCI found this care home to be providing an Adequate service.

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 Hollies 06/12/06

The Hollies 02/12/05

The Hollies 17/08/05

The Hollies 29/01/05

The Hollies 11/05/04

The Hollies 21/01/04

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

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

CARE HOMES FOR OLDER PEOPLE The Hollies 11 Queen Edith`s Way Cambridge CB1 7PH Lead Inspector Lesley Richardson Unannounced Inspection 11:50 30 November 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Hollies DS0000015232.V339697.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. The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hollies Address 11 Queen Edith`s Way Cambridge CB1 7PH 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) 01223 245774 01223 414077 Guy Curtis Care Limited Sandra Catherine Margaret Bailey Care Home 22 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (22), Physical disability (1) The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 DEE, 4 MDE subject to a maximum total from these 2 client groups combined of not more than six of the total 22 residents and 1 PD. 6th December 2006 Date of last inspection Brief Description of the Service: The Hollies is a residential service for older people over 65. The home provides accommodation for up to 22 service users, some of whom may have dementia care needs. The home is situated in an established residential area on the outskirts of the city of Cambridge. It is within easy reach of the city centre, Addenbrookes Hospital and close to good road and rail links. The home provides accommodation on two floors and there is a passenger lift providing access to the first floor. All of the bedrooms are offered as single occupancy with ten having en-suite facilities. There are adequate bathroom facilities available. The home offers generous communal space with two separate lounge areas and a dining room. There are attractively maintained gardens to the front and rear of the property. The charges range from £585 - £640 per week CSCI reports are made available to service users and relatives on request. The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a key inspection of this service and it took place over 6½ hours as an unannounced visit to the premises. It was spent talking to the manager, talking to one member of staff working in the home, talking to one person who lives there and observing the interaction between them and the staff, and examining records and documents. One requirement from the last inspection has not been fully met. There has been one further requirement made as a result of this inspection. Information obtained from the Annual Quality Assurance Assessment and from surveys returned from visitors and people living at the home were also used in this report. Five surveys were returned from people who live at the home, one from a visitor and three from staff members. What the service does well: The home provides care and accommodation to up to 22 older people. People who live at the home say they like living there and comments include, “very caring, happy home”, “I see The Hollies as my home & wouldn’t want to be anywhere else” and “I feel that every aspect of care is covered admirably. Having had experience of other homes we feel that The Hollies gives the residents excellent care in a warm and friendly environment”. An assessment is obtained before people go to live at the home to make sure staff there are able to care for them. People receive contracts and have enough information about the home before they move. People are able to choose how they live each day. There are activities and things to do, and although the number of these have fallen, this has been looked at and is being improved. People said they can get up and go to bed when they want. They can have visitors when they want and they can go somewhere private if they want. Visitors said the home helps their relatives keep in touch with them. The food is good and everyone said they like the meals that are served. The home has a complaints policy and procedure that is displayed for everyone to see. There are very few complaints made and none in the 12 months before this inspection. Everyone we talked to said they know who to speak to if they’re not happy and how to make a complaint. One referral has been made The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 6 to the local safeguarding adults team and the staff member no longer works at the home. All staff have training in how to protect people from abuse. At the time we visited the home was having a new extension finished. Other parts of the home were clean and tidy, and nicely decorated. Everyone we spoke of said they home is always clean and fresh. Staffing levels are acceptable and the home uses agency staff to make sure there are always enough staff on duty. Care staff are only used to help look after people at the home and have specific jobs to do, but don’t carry out other roles like preparing meals or housekeeping. Care staff have mandatory health and safety training, more than half of them have a National Vocational Qualification in Care and the rest are completing this qualification. Other training is given to make sure staff have the skills and knowledge to properly look after people. Money kept by the home on behalf of people living there is done safely. Records are kept to show transactions and the money is held in a safe place. Health and safety, and maintenance checks are carried out at required intervals on all mechanical and electrical systems and products in the home. This makes sure that things are in safe working order for people to use. What has improved since the last inspection? What they could do better: There are still not enough details written in care plans, about what people can do for themselves or what staff members need to do to. Advice and information that has been given by health care professionals is also not written into care plans. This means that agency staff, who are more reliant on information in care plans than permanent staff who know the people at the home, don’t have clear information about the best way to look after people. It also means that the care plans do not reflect the care the person needs or the care they might be given. Medication must not be left unattended where people in the home can access it. Administration records must also be completed properly to show why The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 7 medication has not been given or if additional medication has been used, the reason for this. Temperature checks of medication storage areas must be carried out. Most required checks are completed before people start working at the home. One person started without completing an application form, but other new staff had done this. Checks include an application form and this must be completed to make sure people applying for a job are suitable for the role. 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. The Hollies DS0000015232.V339697.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 The Hollies DS0000015232.V339697.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): 1, 2, 3 and 6 Quality in this outcome area is good. The home has adequate information about people before they live there. This means they are able to make a decision about whether the person can be properly cared for before they moved into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager carries out assessments before people move into the home. Other assessments are obtained from health and social care teams and give more information. We looked at the care records of one person who had moved into the home in the last 6 months. The manager had carried out a pre-admission assessment and obtained an assessment from the social care team. The homes own assessment gave little detailed information, it was in the form of a basic scoring system and there was little other information to supplement the scores given. The manager said this form is no longer being used. However, the social care assessment was very detailed and gave a lot of information about the person. This means the home is able to say whether it The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 10 has the staff with the skills and experience to properly care for someone before they move in. 4 out of 5 people who returned surveys said they had received a contract and they all said they had enough information about the home before moving in. Care records for the person who has only recently moved into the home show they visited before moving in and brought a health care professional with them to make sure the home would be able to meet their needs. Following the draft report of this inspection the provider said a contract may not have been issued if a person was still in a ‘trial’ phase, but they would have received a copy of the terms and conditions. The home does not provide accommodation for the purposes of rehabilitation or intermediate care. The Hollies DS0000015232.V339697.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 adequate. Care records do not give enough information to guide staff in caring for people and medication practice is not always acceptable, which puts people at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person in the home has their own set of care plans that guide staff members in how to care for them. Care plans for three people were looked at as part of this inspection. They show that each person has a plan that gives staff members information about what they need to do to meet most of the identified needs. Risk assessments, for things like falls and moving and handling, are completed and reviewed regularly. Although care plans gave staff enough information, they do not give advice about what staff should do in the event something might happen and they are not updated to show when things do happen. For example, one person’s care plan was looked at because accident records show she had fallen 7 times in the two months before this inspection. The care plan telling staff about her falling The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 12 had been reviewed but did not show how many falls she had had. The reviews showed there had been no changes. The plan also didn’t tell staff what they should do if this person keeps falling. Similarly, this same person has lost 4.5kg in just under a year, putting her at risk of malnutrition. The plan tells staff about her changeable appetite, but it doesn’t tell them what should happen if she continues to lose weight. For example, whether a referral to a dietician should be made. Both this person’s plan and another person’s plan that tells staff about meeting their personal hygiene needs say they need ‘full assistance’. It is likely, however, that both these people would be able to wash their hands and faces. It is important for people with dementia, as one of these people has, to continue doing as much for themselves as possible. If plans tell staff a person needs full assistance this does not give them any guidance about how to help that person maintain skills they may be losing. It is important that these details are written into care plans because the home uses a number of agency staff. This is talked about more in the section about staffing. Permanent staff at the home clearly know the people who live there well and know what they do and don’t like. However, it is these other staff who need to be able to obtain clear and accurate information about how care for people who live at the home, and not have to rely on verbal information. There is a lot of information in care records to show health care professionals, such as specialist nurses, opticians, dieticians and chiropodists, are contacted for advice and treatment. The advice they give staff is not always made part of the care plan though. For example, a doctor and falls co-ordinator had visited one of the people mentioned above and said the number of falls she was having was probably caused by a worsening of her memory and that staff should remind her to use her frame. This information was not in her care plan about falling. Which means that staff reading the plan may not know what they should do without looking through all the other documents that are also in that person’s file. Everyone returning surveys said they always get the care and medical support they need. We saw staff interacting with people living at the home and this showed that staff are polite, attentive and know people well. People we spoke to said staff are “lovely” and “they will do anything for me”. A very positive comment was also received from one relative, “I feel that every aspect of care is covered admirably. Having had experience of other homes we feel that The Hollies gives the residents excellent care in a warm and friendly environment”. There were no negative comments about the home at all. The home uses a system for medication administration using medication administration records (MAR) and blister packs of medication. The MAR sheets are completed, but some entries are not signed or given a code to indicate the reason the medication was not given. One person’s MAR sheets in particular The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 13 indicated no medications for one morning were administered, although there was no explanation for this. This person also had medication missing from a future date in the blister pack. The senior carer said this could have been due to medication having been dropped and another dose needing to be given, but there was nothing in the MAR sheet to show the reason. A requirement has been made regarding medication records. Records are kept to show refrigerated medication is stored at the correct temperature. There are no records to show temperature checks of the medication storage room are taken, although the temperature of the room during the inspection was 9oc. This is acceptable, but checks must be carried out to make sure temperatures in the storage area do not go above the manufacturer’s recommended range. An extension has recently been built on to the home and this includes the medication storage room and during the inspection workmen were decorating the area. The medication room door was left ajar while the senior carer gave medication to a person in the lounge room (2 rooms from the medication room) with blister packs of medication left on the counter in the medication room. Staff said this was only because the door still had wet paint on it. The medication should have been moved to another secure area as leaving it unattended is not safe practice and puts people living at the home at risk. However, as this was due to exceptional circumstances a requirement has not been made. The Hollies DS0000015232.V339697.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. Action has been taken by the home to improve people’s social experience while living there, and this provides a lifestyle that gives good social and community interaction. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 40 (2 out of 5) of people who returned surveys said there are usually enough activities, although 40 also said there are only sometimes activities for them to take part in. Two comments made were, “I like the church services and Communion” and “no activities at present but this is being reviewed”. The home has employed a new senior carer who also has experience organising activities and has taken on the responsibility of organising an activities programme. The programme includes a crossword group and flower arranging. There was little information in the care records to show what people liked to do socially before moving to the home or what they would like to do now they are there. The new senior carer said plans are in place to improve these records, to show what people have done and would like to do. The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 15 Relatives of people and visitors to the home said they are able to visit at any time, their relative is helped to keep in touch with them where that is possible and they are kept up to date with any issues that arise. During the inspection people said they are able to choose when they get up and go to bed, they have a choice of meals and they are able to do what they want during the day. The visitor returning the survey said the home supports people to live how they want to. A main meal was served during the inspection which looked very appetising. The Hollies DS0000015232.V339697.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. People have enough information for them to be able to raise concerns and have them dealt with in the correct way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure that is on display in the home and available to people living there. The manager said there have been no complaints made in the 12 months before this inspection. Information provided to the Commission shows there were 2 complaints made in the 12 months to September 2007, both of these were investigated and responded to within 28 days, but neither was upheld. Visitors at the home and people living there all said they know who to speak to if they’re not happy and how to make a complaint. There has been one safeguarding adults referral in the last 12 months. This was made after the home had investigated concerns about the staff member’s manner and poor working practice. This person is no longer employed at the home. A training matrix for staff members shows that all staff have received training in protecting people from abuse in the last year. The Hollies DS0000015232.V339697.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): Quality in this outcome area is good. The environment offers people who live at the home a safe and pleasant area in which to spend their time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Everyone who returned surveys said the how is fresh and clean and we found this was the case during the inspection in the areas that were not undergoing renovation. An extension has been built onto one side of the home towards the back of the building. This will provide a spacious dining area for people, a medication storage room and a staff room. When building and renovation work is complete there will be two areas where people can sit and relax. Despite building works during the inspection the home was clean and surprisingly dust free. It is nicely decorated and provides a comfortable place for people to live. People are able to bring personal belongings into the home with them to personalise their rooms. Everyone we spoke to and those returning surveys all said the home is always clean and fresh. The Hollies DS0000015232.V339697.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 area is good. There are enough staff with adequate training for them to be able to safely meet the needs of people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the people who returned surveys and people we spoke to during the inspection said there are enough staff at the home. They also said that staff members are usually available when they are needed, and visitors we spoke to said people don’t have to wait too long before staff members are able to help them. One staff member told us that there are two care staff and one supervisor on each shift who are responsible for caring only and do not have other responsibilities like preparing meals or housekeeping chores. Extra staff come in to help at times when it is busier, like lunchtime, and specific jobs are allocated to staff so they all know what they are responsible for. Information provided before the inspection shows there are 14 full time care staff and 6 staff members left the home in the 12 months before this inspection. The home has a good relationship with one agency and uses their staff to cover low staffing levels and used 42 agency shifts in the 3 months before this inspection. The provider told us after the inspection that the use of agency staff in the months leading up to the inspection was due to changes in routine caused by heavy building works, staff illness and additional holiday entitlement for staff. The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 19 All staff receive mandatory health and safety training when they first start working at the home as part of their induction programme. Training records show all staff training in these areas is up to date. Records also show staff members have received training in dementia care, communication and challenging behaviour. Just under two thirds of the care staff have a NVQ in care at level 2 or above and information shows the other 5 staff members completing the qualification. Staff files for 2 people employed since the last key inspection were looked at to see if required checks and information had been obtained before they started working at the home. The files showed this has been done with the exception of an application form for one person who had started working at the home as an agency worker. As all other information was available, a requirement will not be made at this stage. It was discussed with the manager and the provider the importance of obtaining an application form from prospective employees. The Hollies DS0000015232.V339697.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, 35, 36, 37 and 38 Quality in this outcome area is good. The home is run in an open manner, which allows it to be run in the best interests of people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has worked at the home for eight years and has been in the position of registered manager since 2005. She has completed a NVQ at level 4 in management. The provider told us after the inspection that the manager has completed the Registered Managers Award and is also a Registered General Nurse, although the home does not provide nursing care to people living there. The home carried out a quality assurance audit in July 2007. A report has been produced, showing the results in a percentage format of how satisfied The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 21 people were, although there were no details of any comments made. The manager said issues that were raised were dealt with and people living there were told about this in a newsletter. The provider has told us since the inspection that the results of the survey and the actions taken have been displayed in the entrance foyer. We asked the home to complete an annual quality assurance assessment before this inspection, which they did. Policies and procedures are in place, and there was information to show when these had been reviewed in the last 12 months. Money is kept by the home on behalf of people living there; access can be gained through the manager who maintains an accounting system for credits and withdrawals. The records for three people were looked at and found to tally with the money available for these people. People living at the home are also able to keep money with them, if they wish. We made a requirement at the last inspection for staff to receive adequate supervision sessions. Records in staff files show this is now happening and staff members receive supervision more often than every two months. It also shows that staff members are able to ask for supervision if they want to talk about something, and supervision is given in response to issues that have arisen, like medication errors. Information provided before this inspection shows equipment, like hoists, lifts and fire-fighting equipment has been serviced or tested as recommended by the manufacturer. Records for fire equipment and alarm testing were looked at and have been carried out. The Hollies DS0000015232.V339697.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 15(2)(b) Requirement Guidelines for staff must be clearly documented in care plans to ensure that assessed needs are fully met. (Previous timescale for this requirement was not met.) Medication administration records must be kept to show why medication has not been given. Timescale for action 31/03/08 2 OP9 13(2) 31/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team 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 The Hollies DS0000015232.V339697.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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