Inspection on 06/12/05 for Towneley House

This inspection was carried out on 6th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Towneley House 03/10/07

Towneley House 28/02/07

Towneley House 09/06/05

Towneley House 28/10/04

Towneley House 28/04/04

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 Towneley House 143/145 Todmorden Road Burnley Lancashire BB11 3HA Lead Inspector Mrs Pat White Announced Inspection 6th December 2005 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 Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 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. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Towneley House Address 143/145 Todmorden Road Burnley Lancashire BB11 3HA 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) 01282 424739 Mr Stephen Alfred Shillito Mrs Barbara Karen Shillito Care Home 22 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (10) of places Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service is registered to provide personal care for a maximum of 22 service users Staffing levels must be maintained at the levels stated in the home`s proposals, that is, 3 care staff will be on duty at all times between the hours of 7.30am and 10.00pm and 2 waking night staff between the hours of 10.00pm and 8.00am, giving a total 444.5 care hours. In addition there should be a manager on shift for a minimum of 105 hours per week, a minimum of 30 domestic hours and 40 cooking hours. The service is registered to provide care for 10 older people, not falling within any other category and 12 older people with dementia. 9th June 2005 4. Date of last inspection Brief Description of the Service: Towneley House is care home registered to provide personal care and accommodation for 12 elderly people and 10 elderly people with dementia. The home is of an older type building situated in close proximity to Burnley town centre and Towneley park. It comprises 3 floors, linked by a stair lift. Private accommodation consists of 11 single rooms, five of which were at least 10 sq ms, and 5 double rooms, two of which were under 16 sq ms. Nine single and four double rooms were en suite. Communal areas consisted of 2 lounges, a dining room and a smaller dining room/smoke room. Renovations and developments were underway to increase the amount of communal space, increase some bedroom sizes and the number of single rooms, and enhance the facilities. The registered person, Mrs Karen Shillito, was managing the home. Training and assessment material from the Alzheimers Disease Society was in use to ensure staff meet the needs of the residents with dementia. The home had a mini bus that enabled residents to enjoy a range of supported outings and activities to such places as the Trafford Centre, Bury market, the coast and country runs. Residents have had the opportunity of an annual holiday abroad in recent years. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Summary of the Unannounced Inspection on the 6th December 2005 This inspection was an unannounced inspection, the purpose of which was to check: the progress of previous legal requirements and good practice recommendations, check some other important areas of life in the home that should be inspected over the year, other matters in the home which came to the inspector’s notice and check the progress on the renovations that had begun last year. The inspection took 8 hours and 30 minutes and comprised of, talking to residents, a tour of the premises, looking at a small number of resident’s care records and other documents, and discussion with the registered person Karen Shillito and members of staff. Seven residents were spoken with, but only two were able to give their views on the home, and residents were observed in their daily activities. One relative was spoken with. At the time of the inspection there were 16 residents living in the home. Comment cards were left in the home for residents and relatives. At the time of writing the report 7 had been returned. Note The summary is particularly written for residents, and staff are asked to make sure some of the residents are able to read it or made aware of it. The home should also ensure that the full report is widely available to all those who are interested What the service does well: Mrs Shillito had researched the needs of people with dementia and is knowledgeable in this respect. The home uses material produced by the Alzheimers Disease Society to assess the needs, and plan the care, of people with dementia. There was a group of staff who had worked in the home for a number of years and who understand the needs of the residents. They were praised for their kindness and care. The home over the years has demonstrated that it meets the needs of residents who may be classed as “difficult to manage”. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 6 The home provided a wide range of leisure activities for the residents and the residents were taken on trips in the home’s minibus. There was also a regular holiday abroad. One relative said that the home “had a lovely atmosphere with lots of TLC” and was “very welcoming”. The manager is committed to staff training and development. Staff had attended courses according to their own needs and those of the residents. These include NVQ courses, medication training and dementia. The home has consistently followed thorough staff recruitment procedures in accordance with the Care Homes Regulations in order to protect the residents from unsuitable staff. The manager, and registered person, Mrs Shillito, had the relevant qualifications and experience to provide good leadership in the care home. The members of staff spoken to at the inspection confirmed this. What has improved since the last inspection? A number of previous legal requirements and good practice recommendations had been met. The way the registered person decides whether or not the home can meet peoples’ needs had improved. The details of their needs were written down and helped staff understand these needs. The written information about how the staff met these needs had also improved. Some aspects of the way the residents’ medication was organised and administered had improved and this should make sure that medication is given safely and accurately. Some aspects of the premises had improved which directly benefited the residents. The hall, the ground floor WC and first floor corridor had been decorated and there was new lighting. Some bedrooms had been decorated and maintenance jobs had been carried out. Some beds and bedding had been replaced. Other previous legal requirements in relation to the environment had also been met. The management of residents finances had improved to ensure the safe keeping of resident’ monies. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 7 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. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 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 Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 & 5. Standard 6 was not applicable The admission procedures ensured that prospective residents’ needs were assessed before going to live in the home, and helped to determine whether or not Towneley House could meet their needs. The registered person was able to demonstrate how the needs of the residents, including those with dementia, were being met. EVIDENCE: The records of one resident recently admitted to the home showed that a pre admission assessment had been carried out in accordance with legal requirements and standard 3. Both a social work assessment and an in house assessment had been completed and the relatives had visited the home prior to admission. The in house documentation covered all the matters listed in standard 3.3, except religious and cultural needs. Mrs Shillito had also confirmed in writing to the resident that Towneley house could meet her needs. This resident said that she had settled in the home as well as could be expected, and that all the staff were kind understanding. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 10 Records and discussion with staff indicated that staff were committed to meeting the needs of the residents. Positive steps had been taken to meet the needs of the residents with dementia. Material from the Alzheimers Disease Society was used for assessments, activities and staff training. In addition the registered person had completed a 1year college based “ Community Mental Health” course. All care staff had completed an in house course on dementia run by the Alzheimers Disease Society. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The care planning process and documentation had improved, but would still benefit from the inclusion of all aspects of residents’ personal, health and social care needs to ensure these needs are met. The residents’ physical and psychological health was promoted and maintained, and the medication management and systems enhanced this. The residents’ rights to privacy and dignity were respected. EVIDENCE: All residents had care plans, and those with a diagnosis of dementia had detailed assessments and care plans using documentation produced by the Alzheimers Disease Society. Useful personal, life history was recorded. The viewing of records showed that some aspects of care planning had improved since the previous inspection, and that parts of the care plans were written in sufficient detail. However other parts, such as oral care, spiritual matters and some aspects of personal hygiene, should include greater detail. Care plans were being reviewed regularly and there was evidence that some residents had been involved in the compiling of their care plan and the reviews. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 12 The residents’ physical and mental health was monitored and maintained. District nurses were involved in the care of residents with pressure areas and provided advice and equipment. Continence was promoted and managed in the home with assistance from the specialist nurse. The care plans contained information about diet and food preferences but residents’ weights should be monitored and recorded regularly. The registered person was planning to use information from the Alzheimers Disease Society to undertake detailed nutritional screening. Records showed that residents had access to all appropriate health care services including the psychological services for older people. Some aspects of medication management and administration had improved since the previous inspection to ensure the well - being and the safety of the residents. There were areas of good practice which included, all staff administering medication had completed an appropriate training course, and the responsible member of staff checked prescriptions, prior to dispensing. However to further improve medication management, the registered person must ensure that the criteria for PRN (“when required”) and variable dose medication is clearly defined and documented and that any alteration and addition to the instructions on the MAR sheets (“transcribing”) are dated and double (witnessed) signed. Medication that requires storage in the fridge should be kept in a lockable facility. Residents’ rights to dignity, respect and privacy were understood by the staff and upheld. This was confirmed by some of the residents spoken with. One resident said that the staff were “very good and kind” and treated her appropriately. The 7 residents who completed comment cards stated that they felt well cared for, that the staff treated them well and that their privacy was respected. Members of staff were observed treating residents with kindness and respect. Since the previous inspection a complaint had been made regarding the physical condition of a resident admitted to Accident and Emergency. A full investigation had been undertaken by the home. This indicated that whilst some of the observations made at Accident and Emergency were correct, there were justifiable reasons for this, and there was no evidence of poor care practices. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 14 Varied social activities were provided which were enjoyed by some of the residents, including those with dementia. Residents were encouraged and supported to maintain contact with family and friends, and visitors were made welcome in the home at any reasonable time. Residents had choices in some areas of their lives, though for some residents this was limited due to mental impairment. EVIDENCE: Residents are offered a lifestyle in the home that matches their experience and expectations. Routines were flexible enough to suit individual preferences, such as what time to rise and retire to bed. Records showed that a variety of activities were arranged, such as entertainers, singers and trips out in the home’s minibus. Visits were made to shopping centres, pubs, restaurants and local places of interest. Mrs Shillito stated that they provided activities suitable for people with dementia. Some residents enjoyed group holidays in Spain. One resident spoken with, and the 7 who completed comment cards, stated that the home provided suitable activities. Residents were encouraged and supported to maintain contact with family and friends and the local community. There were relatives in the home at the time Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 14 of the inspection. One relative confirmed to the inspector that relatives were made welcome at any reasonable time, and that staff were friendly and kind. Residents were encouraged to have some choice and control in their lives, in accordance with their mental ability. There were choices regarding whether or not to take part in activities and the food served. Residents wore their own clothes and could bring small items of furniture with them for their bedrooms. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home had a complaints procedure that relatives could access, and residents indicated that they knew who to speak to if they had concerns. Complaints were investigated appropriately. The home’s policies and procedures helped to protect residents from abuse. EVIDENCE: The complaints procedure was in compliance with Regulation 22 and a copy was in the Service User Guide and on the home’s notice board. In the last 12 months two complaints had been made, one directly to the CSCI and one to the home. The home had investigated both complaints under its complaints procedure, and this had been done appropriately. The outcomes have been summarised in the relevant sections of the report. Residents, including the 7 who completed comment cards, stated that they had no complaints about the home and that they knew who to speak to if they were not happy. The home had policies and procedures for the protection of the residents from abuse that were in accordance with this standard, and included a whistle blowing policy. There had been no recently reported suspicions or allegations of abuse and no member of staff had been referred to the Protection of Vulnerable Adults register. “Adult abuse” was included in NVQ courses. The 7 residents who completed the comment cards stated that they “felt safe” living in the home. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 19, 20, 21, 24 & 26 Work was in progress to extend and develop the property, and so improve the accommodation and facilities for the residents. Improvements in the décor, maintenance and furbishing of some parts of the home had already been made. The safety and comfort of the residents was being maintained whilst the building work was progressing. The home was clean free from unpleasant odours. EVIDENCE: At the time of the inspection the registered provider Mr Shillito was working on an extension and improvements to the home. These developments include a conservatory, an extended dining room, a passenger lift, an increase in the number of single bedrooms and WCs and a “treatment room”. It was positive to find that the registered persons were making sure that satisfactory standards of decor and furbishing in the residents’ living areas were being maintained throughout this. In addition some areas of the home including the hall, stairs, the first floor corridor and two WCs had been improved since the Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 17 previous inspection. There was new lighting in some areas of the home. New carpets had been ordered for some areas. Residents’ safety was also being maintained. The registered person carried out regular audits of the property to ensure all areas of the home and its facilities were adequately maintained. This was reflected in the overall improvement of parts of the home including the bedrooms. The registered persons must ensure that the new rooms, including the bedrooms, meet all the Legal Requirements and the National Minimum Standards for Older People. The area to the rear of the building was under construction and could not be used by residents. However safe access to the courtyard beyond was maintained. There was a patio area at the front of the building. Communal space at the time of the inspection consisted of 2 front lounges, a dining room and a rear smoking area with a patio door. This was to be increased with the addition of a conservatory and an extended dining room. The communal areas were furnished in a comfortable and homely style and improvements to the decor and new carpets in the two front lounges were planned. However the registered person must ensure that the existing bedside table and the mattress cover in the bedroom identified are replaced. It is also highly recommended that the seat on the stair lift is re - covered. The home was clean and free from offensive odours and the laundry facilities were new and in good condition. These and the written procedures helped to ensure the control of infection. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 The staffing levels appeared to be adequate for meeting the needs of the current group of residents. Staff training and development had been developed according to the needs of staff and the residents, and most staff had completed relevant training courses. Staff appeared experienced and competent EVIDENCE: There was evidence from the rotas supplied, and observation at the time of the inspection, that staffing levels were meeting the needs of the current numbers of residents. However at the time of the inspection there was no designated cook in the home. Care staff were carrying out cooking duties, until a new cook is appointed. There was evidence that over 50 of care staff were trained to at least NVQ level 2. There were staff training and development records that showed that most staff had undertaken training in dementia, updated moving and handling, first aid, health and safety and infection control. Some had completed a “protection of vulnerable adults” course. Staff spoken with confirmed that the manager was committed to training and development. Those new members of staff that commence work without relevant qualifications will complete an Induction training course based on the specifications of “Skills for Care”. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 & 38 There had been 3 changes in the management of the home in the last few years and the registered provider, Mrs Shillito, was again managing the home after the recent departure of the registered manager. She was competent and experienced and had the relevant qualifications. The residents and staff would benefit from a period of stability in management from a competent and experienced person. The frequency of formal staff supervision in the home could be improved. The registered person ensured a safe environment for residents and staff. EVIDENCE: Over the last two and a half years there had been 3 changes in the management of the home and the most recent registered manager had recently left her appointment. The registered provider Mrs Karen Shillito was again managing the home, as she had done prior to the appointment of a “registered manager”. She had the necessary qualifications, knowledge skills and experience, including knowledge in the care of people with dementia. Her Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 20 return to management was seen as a positive development by the staff spoken with, and it was agreed that the residents and staff would benefit from a period of stability in management from a competent and experienced person. There was a deputy manager in post, and a team of senior carers. The deputy manager had a number of years experience of working in the home and was studying for NVQ level 4 qualifications. Mrs Shillito was seen as supportive, “easy to work with” and encouraging of staff training and development. Regular staff meetings were held Since the previous inspection a quality survey, involving resident questionnaires, had been conducted. These questionnaires covered all the main areas of life in the home. A report of the results and action was given to the CSCI. The manager stated that there were plans to extend the survey to visitors and staff. Residents meetings were held every few months. The former manager, and Mrs Shillito, had ensured that a number of requirements and recommendations from the previous inspection had been met, including ensuring that the residents’ financial interests were safeguarded. Annual staff appraisals had been carried out and staff were supervised and supported on a day - to - day basis. However the manager should ensure that formal one to one supervision according to standard 36 recommences. The registered person ensured a safe environment for residents and staff. Members of staff were suitably trained in moving and handling, first aid, fire precautions and infection control. The equipment and appliances had been appropriately tested but the gas boiler and central heating system required servicing. Accidents and incidents were recorded and reported appropriately. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X 2 X 3 STAFFING Standard No Score 27 3 28 4 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 x 2 Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15,17(1a) Sch 3 mn Requirement The care plans must detail all relevant aspects of the residents health, personal and social care needs, including those relating to oral care, spiritual matters and all aspects of personal hygiene. (Previous timescale not met) The criteria for the administration of PRN and variable dose medication must be clearly defined and recorded. (Previous 2 timescales not met) The registered person must ensure that all forms of transcribing on the MAR sheets are dated and double (witnessed) signed. The registered person must ensure and demonstrate to the CSCI, that the size and layout of the new bedrooms are suitable for the residents’ needs. The registered person must ensure that a suitable bedside table/cabinet is provided, and the mattress cover is replaced, in the bedroom identified. The registered person must DS0000009456.V253278.R01.S.doc Timescale for action 31/01/06 2. OP9 13 (2) 31/01/06 3. OP9 13 (2) 06/12/05 4. OP23 23 (2)(f) 31/03/06 5. OP24 16 (2)(c) 31/01/06 6. OP25 23 (2)(p) 31/03/06 Page 23 Towneley House Version 5.0 7. OP38 13 (4) (a) & (c) ensure and demonstrate to the CSCI, that the lighting in the new bedrooms is suitable for the residents’ needs and according to standard 25.3 & 25.6 The registered person must ensure that the gas boiler and gas central heating system is serviced 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7 8. Refer to Standard OP3 OP7 OP7 OP8 OP9 OP9 OP22 OP36 Good Practice Recommendations It is recommended that the in house assessment includes all the matters listed in standard 3.3, including religious and cultural matters. It is recommended that residents weight is monitored and recorded. It is recommended that the care plans include sufficient details in all matters listed in standard 3.3 including a risk assessment for falls. It is recommended that detailed nutritional screening is undertaken Medication requiring fridge storage should be kept in a lockable facility. Where drops are to be used in both eyes, separate bottles should be used for each eye to avoid cross-contamination. It is highly recommended that the seat on the stair lift is re covered with a more suitable material. The manager should ensure that formal one to one supervision according to this standard recommences. Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Towneley House DS0000009456.V253278.R01.S.doc Version 5.0 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. 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!