Inspection on 23/08/06 for Wellesley Road

This inspection was carried out on 23rd August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wellesley Road 17/10/07

Wellesley Road 14/11/05

Wellesley Road 30/07/05

Wellesley Road 22/11/04

Wellesley Road 27/05/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

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

CARE HOMES FOR OLDER PEOPLE Wellesley Road Wellesley Road 1 Wellesley Road London NW5 4PN Lead Inspector Ms Pippa Canter Unannounced Inspection 23rd August 2006 10:00 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 Wellesley Road DS0000037326.V287320.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. Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellesley Road Address Wellesley Road 1 Wellesley Road London NW5 4PN 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) 020 7267 0856 020 7424 0999 katherine.williams@camden.gov.uk London Borough of Camden Miss Katherine Williams Care Home 48 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (48), Mental disorder, excluding learning of places disability or dementia (2), Mental Disorder, excluding learning disability or dementia - over 65 years of age (48), Old age, not falling within any other category (48), Physical disability (2), Physical disability over 65 years of age (48) Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 beds in short stay unit registered for adults under the age of 65. Date of last inspection 14th November 2005 Brief Description of the Service: Wellesley Road is a care home providing personal care for up to 48 older people. The home caters for both male and female service users who are aged 65 years and older. The certificate of registration reflects that the staff are caring for people within the categories of dementia, mental disorder, old age and physical disability. The home not only provides long-term residential care but also three separate units for emergency admissions, respite and interim care. The current level of fee is £679 per week. The permanent service users are accommodated on the ground floor and the three other services are on the first floor. The units are self contained and staffed separately. They are organised so as not to impact on the lives of the long stay service users. The owned is operated by Camden Council and has been registered under The Care Standards Act 2000. It is situated with good access to public transport, shops and community facilities. The home was purpose built about thirty years ago therefore not all the rooms sizes and corridor widths meet with the national minimum space standards. All the bedrooms are single occupancy however forty of them are slightly below the national minimum space standard and eight of them measure over twelve square meters. The home is three storeys high although accommodation for service users is on the first two floors only. A shaft lift gives access to the second floor; the third floor is not registered. Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over the course of one day. The visit lasted a total of 7 hours. The Registered Manager was not available so the inspection process was assisted by the person in charge along with additional input from the staff on duty, service users and some visitors. Records such as care plans, daily logs as well as accident and incident logs were examined. A tour of the building was made with attention to the rooms of the service users being case tracked. Some service users were asked for their views of the running of the home and talked about their experiences of living there. Relatives also contributed their comments. Staff were observed carrying out their duties and were involved in general discussion with the inspectors. Prior to the inspection the manager returned a pre-inspection questionnaire. A service user and a general practitioner returned questionnaires giving their views about the home. At the end of the visit feedback was given to the person in charge. A comment card about the inspection process has been left at the home for completion and return to the Commission for Social Care Inspection (CSCI) A requirement made at the last inspection has not been yet been met and has been restated in this report, with a new timescale for compliance. In the “Timescale for Action” column, the date in ordinary type relates to the timescale given at the last inspection. The date in bold type relates to the new timescale. Further information about the unmet requirement can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale, without a valid reason, may lead the Commission for Social Care Inspection considering enforcement action to secure compliance. What the service does well: Service users feel at home and relaxed at Wellesley Road as staff pay close attention to meeting their individual needs. Service users said that they enjoyed living in the home and were very happy with the standard of care they received. Relatives were also positive about the quality of the care in the home and emphasised that they are made to feel welcome when they visited and that they appreciated being able to visit whenever they wanted. Both service users and relatives said that they felt able to talk to the manager or the staff if they had any concerns or worries. The home has an experienced manager who is keen to set high standards for the home. Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 6 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. Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 7 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 Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 8 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&6 The quality in this outcome area is considered to be good. This judgement has been made using available evidence, including visits to the service. Staff have a good understanding of the service users’ support needs and aspirations through the assessment process. EVIDENCE: The care records of four service users were looked at; two of whom had been admitted since the last inspection. Community care assessments were available and previous inspection reports provided corroborative evidence. A service user guide was supplied as part of the pre-inspection information. It states clearly that one of the criteria for admission is that the person must have been assessed by a care manager/social worker. Allied to this a completed needs assessment must be provided to the home by the assessing care manager at the time of the referral. An inspection of the care records showed that service users are subject to the care management approach prior to admission. Copies of social worker assessments are available and it is clear that the home undertakes its’ own pre-admission assessment of need. Records of pre-admission visits are on file. Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 9 It is also clear from the care records that care plans are updated following a six-week trial. In addition to permanent care, the home provides a service for emergency admissions, respite and interim care. There is dedicated space provided with separate teams of staff. One service user commented “I am very happy with the care I get here.” Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The quality in this outcome area is considered to be good. This judgement is made using available evidence including visits to the service. Service users benefit from the close attention paid by staff at the home to meeting their health care needs. There has been an improvement in the content of the individual care plans, which accurately reflect the needs of the service users. However social profiles need to be developed. The systems for medication are satisfactory but there needs to be improved recording on the medication administration sheets. Personal care is offered in such a way as to promote and protect the service users’ privacy and dignity. EVIDENCE: In total four care plans were looked at and seven service users contributed their views during the inspection. One general practitioner returned a comment card along with a relative. Care staff were observed interacting with service users carrying out their duties. The daily records were looked. The pre-inspection information provided details on how service users have access to health and remedial services. The records of four service users were looked at and showed that for each one there was a current care plan, which set out the needs of the service user, how they are to be met by the home and with evidence that these were being Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 11 reviewed regularly. In addition each file contained an assessment of any areas where there was considered to be any risk to the service user and how these risks were to be dealt with and reduced as far as possible. The care plans include service users’ need at nighttime. An inspection of the care plans showed that service users have had input into their development. There is evidence of falls risk assessments as well as manual handling and environmental hazards. What seemed to be lacking from the care records inspected on this occasion was a social profile for the service users. Please see Requirement 1 The pre-inspection information recorded how service users have access to health care professionals, including GP, district nurse, optician, dentist, chiropody, audiology, occupational therapist, speech therapist and a community psychiatric nurse. There was confirmation from the care records and discussions with service users confirmed that this access is available. The service user questionnaire confirmed that they receive medical support as required. The GP who returned a comment card confirmed that staff have a clear understanding of the service users’ needs. All service users are registered with a GP for the prescribing of medication. The home has a policy and procedure for the administration of medication, which, includes the use of homely remedies. The pre-inspection information identifies that all permanent care staff including managers and seniors are responsible for the administration of medication. Training information shows that staff have attended training in respect of medication. A small audit of each medication cabinet on the separate units showed that the medication administration records were not being completed correctly. There were two occasions when it was not possible to tell if prescribed creams had been administered and on a further three occasions medication had been stopped e.g. Paracetamol, Movical and Senna but there was no date or signature on the MARS sheet. Please see requirement 2. The inspector received positive comments from the service users who participated in the inspection process. Comments such as “I am well cared for”. The care plans reflected the values of privacy, dignity, choice and independence. Discussion with service users highlighted that staff respect both privacy and dignity. This was also reflected in the care practice of the staff when they were observed carrying out their duties. Service users are assessed as to whether they can manage a key to their rooms. One service user confirmed that they are able to lock their room during the day and at night; and staff always ask permission to enter. Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 12 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 & 15 The quality in this outcome area is good. This judgement has been made using available evidence, including visits to the service. Wellesley Road is good at making service users feel at home, comfortable and that they are well looked after. Service users are able to choose from a range of activities but would benefit from a range of more individual social events and outings. Service users have nice food in nice surroundings with individual preferences catered for. EVIDENCE: A programme of activities was included as part of the pre-inspection information. These included events in the home as well as in the community e.g. visiting the local Queens Road market. Feedback from service users showed that activities are available and they can participate in them according to choice. An activities room has now been developed on the first floor. Separate staffing hours are allocated to organising activities. Discussions with staff highlighted a need to develop the area of social activities to introduce more opportunities for staff to support service users in more individual activities. This was echoed by a service user, who because of visual and hearing impairments felt unable to participate in group activities and would prefer being escorted out into the community. If social profiles were Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 13 developed as part of the care planning process then this will enable staff to develop more individual activities for service users. Visitors said that they were welcomed into the home and that they can visit their relatives and friends in private. A visitor’s book maintained at the front door shows that the home operates an open door policy. Staff were observed engaging with visitors in a positive way. There is also a visitors’ comments book maintained at the front door. This contained some very complimentary remarks such as “Many thanks to the staff who take such wonderful care of my mother” and “Many thanks to you all for your kindness and care”. However it has had no recent entries for some months. The purpose of this comment book needs to be reviewed and promoted if visitors are to continue making entries. Discussions with service users and staff highlighted that service users are able to follow their preferred lifestyle. Care plans reflect personal preferences. The routines on the individual units are flexible to ensure service user’s needs can be met. Throughout the inspection staff were observed offering service users choices. Service users said that the food was very good and they get a choice. Menus show that alternatives are available from the main courses on offer as well as variety. Medical and cultural needs are also being met. Likes and dislikes are recorded as part of the care planning process. During a tour of the premises, it became apparent that menus were not accessible to service users. Please see requirement 3 Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 14 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 quality in this outcome area is good. This judgement has been made using available evidence, including visits to the service. Arrangements for protecting service users are satisfactory and keeping them safe from possible risk or harm. Service users are listened to and their views acted upon. EVIDENCE: Complaints records were examined. Feedback was received from service users and visitors. There was discussions with staff about their understanding of adult protection and what their responsibilities were in reporting suspicions or allegations of abuse. The pre-inspection information records that the home has received four complaints and three of them have been substantiated. The service has introduced an internal but informal complaint’s procedure to inform service users who they should speak to if they are unhappy and how to complain. A copy of the complaint’s procedure was attached with the pre-inspection information. It is also on display around the home. The comment card from the service user confirms that they know what to do if they are unhappy. Discussions with the service users in the home highlighted that they felt comfortable about approaching staff if they were unhappy about their care. The in-house policies and procedures on adult protection and whistle blowing are contained within the home’s operational policy. The provider operates a rolling programme of training on adult protection. Staff also confirmed that Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 15 there is a training video available for use in the home. Discussions with staff highlighted that they had attended training on adult protection. They had a grasp of what constitutes abuse and what action should be taken. There are clear guidelines for handling service users’ monies and a thorough and robust recruitment and selection procedure. Staff attend training in respect of dementia and challenging behaviour, which enables staff to manage what can be difficult situations with confidence. Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 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 & 26 The quality in this outcome area is adequate. This judgement has been made using all available evidence including a visit to the service. Although there has been some upgrading to facilities, there is still a need for investment in the home to ensure that it will provide an attractive and safe environment for service users. EVIDENCE: Since the last inspection a new shaft lift has been installed however the carpet in the main foyer has not been replaced as identified at the inspection in November 2005. The last two inspection reports 30.07.05 and 14.11.05 referred to the need to repair cracks in the stairwell (Blue Unit). There has still been no movement in respect of this repair. It is understood the cracks in the stairwell are subject to an ongoing investigation into a possible shift of the foundations. During a tour of the home it was also apparent that there are still outstanding repairs recorded as part of the inspection in November 2005. These are as follows:Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 17 • • • The sliding door to the ground floor disabled toilet is very stiff and service users were unable to manage the door without assistance from staff. This toilet, although classified for disabled use, will not accommodate anyone requiring the assistance of two care staff. The sluices on both floors require replacement, particularly the one on the ground floor, which has a very rusty surface. Room 40, the lock to the wardrobe door is not closing correctly. During the tour there were further areas noted for improvement. These are as follows:• The cupboard doors in the kitchen/diner, Interim Unit, should be replaced. They are currently untreated MDF. • The windows in the kitchen/diner in the Interim Unit need cleaning. • The service users’ lounge in the short stay unit looks sparse and uninviting. • There are too many notices on display e.g. pertaining to diarrhoea and vomiting also about overtime. Throughout the inspection the home was found to be clean and hygienic. Discussions with service users and visitors indicated that they considered a good standard was being achieved in this area. Wellesley Road DS0000037326.V287320.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The quality in this outcome area is considered to be good. This judgements has been made using available evidence, including visits to the service. Progress is being made to recruiting to vacant posts, establishing a team of well-trained staff who will offer consistency of care within the home. Service users are protected by the home’s recruitment and selection process. EVIDENCE: The pre-inspection information provided relevant data about staffing and staffing levels. Staff were observed carrying out their duties. Service users and visitors were asked for their views. Training records as well as staff rotas were looked at. The pre-inspection information showed that 90 of the staff have achieved an NVQ 2 or above. Training records show that staff have attended core training such as health and safety, manual handling, basic food hygiene, medication and first aid. They have also been involved in training for Links communication and dementia, falls screening, computer training and feet care and toenail cutting. Training which is planned for the future includes equality and diversity, protecting vulnerable adults and updates in medication training. There is clear evidence that staff are attending training, which is relevant to their work and to meet the needs of the service users. There is a clear management structure in place with a manager and a team of assistants; therefore there is always a senior member of staff on duty. There are dedicated catering, laundry and domestic staff. The feedback from the service users and the visitors is that there are sufficient numbers of staff Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 19 deployed around the home; and the rotas confirmed this. This can be a busy home with several admissions and discharges each day. The staff group is balanced to enable service users a choice of male, female and age related preferences. A sample of recruitment files were looked at some months prior to the inspection. The providers are re-organising how the personnel records will be kept, which will be an improvement. The Commission is satisfied that the provider operates a thorough and robust recruitment and selection process Wellesley Road DS0000037326.V287320.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 The quality in this outcome area is good. This judgement is made using all available evidence including visits to the service. The home is being well managed. Arrangements are in place to promote the health and safety and welfare of service users. A system is in place for self-monitoring through formal and informal means. EVIDENCE: The home is managed by an experienced and suitably qualified manager. The manager has been in post for nearly two years and has successfully completed the fit person process. She is supported by a team of assistant managers and senior care staff and also received support and supervisions from the Project Manager for Residential Services. There are policies and procedures on handling service users monies and valuables. The pre-inspection information shows that service users’ personal Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 21 finances are managed in the most appropriate way. Two service users manage their own financial affairs, whilst two are subject to Power of Attorney. All service users have access to their full personal allowance. A sample of financial records were looked at and found to be accurate. Accounts allow for an audit trail The service has circulated satisfaction survey forms to every relative or friend of all the service users in the home. Visitors were asked to comment on the welcome they receive, the degree of privacy and about the quality of the communication with the home. The home received some very positive comments. Any critical feedback is addressed by the home. A satisfaction survey amongst the service users will also be conducted annually. The home has a health and safety policy in place and staff undertake appropriate training. Risk assessments are in place for COSHH. A contract is in place for the collection of clinical waste. Records show that equipment is serviced and there is a system in place to report repairs. During a tour of the premises there were no hazards observed. Water temperatures are regulated. A system to test alarm bells is in place and staff are aware of how to respond in the event of a fire. Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Wellesley Road DS0000037326.V287320.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 Requirement The registered person must ensure that each service user has a social profile as part of the care planning process. The registered person must ensure that when a resident’s medication is altered, care staff are responsible for amending the MAR. • cancel the original direction • write the new directions legibly and in ink on a new line of the MAR • write the name of the doctor or other prescriber who gave the new instructions • date the entry and sign (including a witness when this is possible). • There needs to be an entry in the daily records to corroborate the change to the prescription. The registered person must ensure that menus are accessible to service users. DS0000037326.V287320.R01.S.doc Timescale for action 31/12/06 2. OP9 13(2) 30/10/06 3. OP15 16(2)(i) 30/10/06 Wellesley Road Version 5.2 Page 24 4. OP19 23(2)(b) The registered person is required to keep all parts of the home used or occupied by service users in a good state of repair. The areas requiring attention are listed in the main body of the report under Standard 19. This requirement is being restated in part. 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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 Wellesley Road DS0000037326.V287320.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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