Inspection on 28/04/06 for Wessex Lodge

This inspection was carried out on 28th April 2006.

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

Wessex Lodge 15/05/07

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Wessex Lodge Jobson Close Newbury Road Whitchurch Hampshire RG28 7DX Lead Inspector John Vaughan Unannounced Inspection 09:45 28 April and 5th May 2006 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 Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 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. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wessex Lodge Address Jobson Close Newbury Road Whitchurch Hampshire RG28 7DX 01256 895982 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) Hestia Care Limited Mrs Veronica Sharon Bovill Care Home 40 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (40) of places Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First Inspection of the Service Brief Description of the Service: Wessex Lodge is a large purpose built service registered to provide nursing care to forty service users who are over the age of sixty five. The home can also admit up to ten people who have Dementia. The homes is owned and managed by Hestia Care Ltd and the registered manager is Mrs Veronica Bovill. Accommodation is provided on three floors and there are forty individual bedrooms with en-suite facilities. The home is located close to the village of Whitchurch and its local amenities. The home shares a site with another registered nursing home Berehill which is also owned by Hestia Care Ltd. The manager provided information for the inspection to indicate that the fees for the home range from £500 to £800 per week. This report will be made available in the home to all service users and visitors and it will be attached to the statement of purpose and service user’s guide. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection of this service and it included two visits to the home. The inspector met with service users, family members and their representatives. The inspector also had written feedback in the form of a questionnaire. The manager of the home met with the inspector during the visits staff were interviewed and observed and records held in the home were sampled. The inspector also toured the home. What the service does well: What has improved since the last inspection? This is the first inspection of the home. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 6 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. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 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 Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. The home can demonstrate that service users needs will be correctly identified and acknowledged. This home does not provide intermediate care. EVIDENCE: The inspector had the opportunity to meet with care managers visiting the home over the two days of inspection. These discussions confirmed that service users have a full assessment of their needs before moving into the home and reviews are arranged at the end of trial stays to ensure the home is meeting that persons needs. Assessments and care plans were sampled and these documented the needs of the individual, interests and likes and dislikes. Health care assessments have also been completed with nursing intervention strategies. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 9 The inspector met with service users who recently moved into the home and they talked about there experiences of moving to the service. Family members supported them with their move which included visits to see the home and looking through information provided by the service about what can be provided for them if the decided to move into the service. Family members visited the home during the inspection and they took time to speak to the inspector confirming that information was provided to the home on the needs of service users and this has been documented in their assessment. The home does not provide intermediate care for service users. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. Services user’s plans demonstrate that service users needs and wishes are acknowledged and responses to meet these needs are documented. The medication administration practices are not satisfactory and do not fully demonstrate that safe practice exists in the home. The home provides support for service users to access Health Care professionals to meet their needs and the practices of the home mean that service users are treated with respect and their dignity is maintained. EVIDENCE: Each service user has a care plan and the inspector examined a sample of six of these plans during the visit to the home. The plans cover activities of daily living including eating and drinking, healthcare, mobility, personal care, social activities and any specific nursing interventions required. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 11 The care plan uses a form that has a number of standard statements in each of the areas of daily living and present actions that staff need to take. The person making the assessment deletes the parts that are not relevant. The inspector noted that some of these plans had statements that had not been deleted and some areas had not been fully completed this could lead to confusion about the individuals needs. The manager agreed to rectify this and discussed the current format with the inspector. The manager stated that they are going to look at introducing a new format in the future to enhance the current care planning system. The inspector noted appropriately completed monitoring records for weight, fluid and nutritional needs. Regular assessment of risks related to pressure care, mobility and nutritional need are undertaken. The inspector also noted that one person’s first language is not English and staff names who can communicate in the language have been recorded to ensure support can be provided. One service user requires nursing care with a pressure ulcer and the intervention plans are appropriately documented. The inspector noted that the nurse reviewing progress with the treatment of the wound had contacted the tissue viability nurse for advice. Service users files contained information to confirm regular contact with healthcare professional and General Practitioners (GP) visited service users during the inspection. The inspector examined the medication practices in the service and looked at the storage and recording of medication. The homes medication is stored appropriately and records are maintained of all medication administered and disposed of in the home. The correct facilities are available in the home for the safe disposal of unused medication. Some medication times have been altered on the record and one tablet is being given as ‘when required’ although it is still prescribed as three times a day on the medication record and prescription label. There was no evidence of these changes being agreed by the GP. The stock recording has not been completed for this month however the inspector saw previous records to confirm that this is usually completed. The inspector also found tablets still in the blister pack for a service user however the record did not match and did not indicate why they were still there. These concerns were discussed with the manager and they were required to take action to change the prescriptions with the GP and pharmacist and to investigate the omissions on the administration records to ensure practice is improved. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 12 Service users told the inspector that the feel well cared for and staff are available to support them when the need help. The inspector was told by service users and family members that they are always treated with respect. Staff were observed talking to service users in a valuing way, responding to their requests and reassuring individuals who were anxious. Staff knocked on doors and waited to be invited in to the room before entering. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. Service users receive a service that meets their social and leisure needs and this is enhanced by a service that welcomes and encourages family contact. The practices in the home support service users to make decisions about their lives. Service users receive a well-balanced and varied diet reflecting their likes and dislikes. EVIDENCE: The service has a member of staff who coordinates activities and events in the home. The inspector met with this person and discussed their approach and the activities that they have organised. Daily activities are organised and the inspector observed staff engaging with service users in a quiz and music sessions while visiting the home. An activity board is displayed in the lounge and the co-ordinator keep a record of sessions Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 14 who has participated and reviews they keep this under review to ensure everyone has a opportunity to participate in activities they enjoy. Activities include board games, bingo, music and movement, discussions and reminiscence work, arts and crafts and aromatherapy. The coordinator has developed session plans for these activities to keep them consistent and meaningful for service users. The inspector was told that Wednesdays are spent in smaller groups and one to one sessions with those individuals who do not want to join in the larger activities. A family member commented that their relative has become more active socially since moving to the home and participates in activities and spends time with other service users. The inspector observed service users during the visits to the home and they were relaxed and appeared comfortable in their surroundings. Trips are organised to go to pubs for meals, two local garden centres and a farm. A registered pat dog also visits the home. Local clergy also visit the service. Two service users attend a day service outside of the home. Feedback from service users, family members and care managers confirmed that the home is very open and relaxed and visitors are made welcome and actively encouraged. The inspector spoke to service users during his visits to the home and they commented on being consulted about their needs and wishes, given choice about what to do, how and where to spend their day and their preferred meals and drinks. Staff were observed responding promptly to service users who were anxious and supporting them with their requests. The home has a chef who discussed the catering provision with the inspector. A four-week seasonal menu is in place and this has a variety of meals with alternatives being offered and recorded. A new summer menu is being introduced shortly and some changes are being made by the Chef following feedback from staff and service users. The chef has introduced a catering record and diary system recommended by the environmental Health Officer that helps to record information on food provision and monitors practice. A likes and dislike sheet was seen and the chef is confident that they can cater for specific requirements of service users cultural or religious needs and they would seek advice to ensure they could meet these needs correctly. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 15 The inspector observed the meal times in the home and these were relaxed, unhurried and the food was very well presented and looked appetising. Service users commented that the food was very good and they had plenty of choice and if they didn’t like a particular meal they could have something else. The home’s dinning room has only enough spaces for twenty four service users to sit and have a meal. A present a number of people have their meals in there own room and a married couple have their own lounge were they take their meals. The manager agreed that they would need to look at how they could seat all forty people in this area if they chose to take their meals in the communal area at the same time. The manager suggested the purchasing of more tables and chairs to ensure that this could happen. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. Service users can be confident that the home has systems in place to acknowledge and respond to their concerns. Procedures to protect service users from abuse are in place however training is required to fully demonstrate that staff members are aware of these policies and procedures. EVIDENCE: The homes complaints record was examined to confirm that no complaints have been received. A complaints policy and procedure are in place and available to all service users and visitors to the home. The manager stated that they are looking to set up regular meetings with service users and families to look at how the home is performing and discuss any areas that need to be developed. Service users and family members said that they knew how to raise a concern if the needed to and would talk to staff or the manager if they were unhappy. They were confident that they would be listened to by the staff team and the manager. The service has a clear policy on the protection of vulnerable adults and this has been linked to the Hampshire multi-agency procedures for the protection Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 17 of vulnerable adults. The home also has an up to date copy of the multi agency procedures. The manager stated that staff have been given a leaflet prepared by the home which identifies abuse and how to recognise the signs of abuse. Training for the staff team has not been completed however the manager stated that they have obtained a training pack and staff will be trained using this pack throughout May. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 18 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, 23 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. The home provides a comfortable, clean and well-maintained environment enhanced by alternative communal areas and individually styled and furnished rooms to meet service user’s needs. This will be enhanced by clear risk assessment strategies for outdoor spaces and open stairwells. EVIDENCE: The home has been built on the grounds of another registered service and provides forty single bedrooms with en-suite facilities. The inspector toured the premises with the manager and discussed the facilities with service users during the visit. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 19 Most service users make use of the large lounge on the ground floor and service users were also using additional seating in the dining area during the visit. Married couples that wish to share a bedroom have been provided with a second room that they use as a living room. The service users stated that they were very pleased with the arrangements and had all the facilities in the room they needed. A small lounge is available on each of the other two floors in the home however these rooms are rarely used and the manager is looking at ways to develop the use of these areas. The manager and inspector toured the outside of the building and this is still under development. Pathways leading around the building have steep drops to the side in places as the soil levels have not been resolved and the manager was asked to carry out a risk assessment to demonstrate how service users would safely access these areas until the work was completed. A courtyard patio area can be accessed from two of the ground floor bedrooms and a communal area and these doors have ramped access. The inspector noted that there are no hand rails and the door thresholds are much higher than the ramps. The manager stated that they would need to complete risk assessments to ensure service users do not trip or slip in these areas. Raised planters are in place and the activity co-ordinator has plans to work with service users to fill these beds. Service users with bedrooms overlooking this area said they looked forward to seeing the flowers grow. The dinning room does not provide sufficient seating facilities to cater for all service users if they wish to take their meal in this area and the manager agreed to look at this concern and find a suitable arrangement if this should arise. The home was clean and tidy and free from any unpleasant smells. The home has a laundry with washing machine that has appropriate disinfection programmes. The room itself was clean and the floors and walls are readily cleanable to ensure the chances of infection and cross contamination is reduced. The inspector observed staff using appropriate protective equipment such as gloves and aprons and each floor of the building has an appropriate sluice facility. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 20 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. Service users are supported by sufficient staff who are trained and supervised however the home cannot fully demonstrate that staff have obtained all of their mandatory training. The recruitment practices of the home are robust and protect service users. EVIDENCE: The home provided a rota to confirm that sufficient staff are on duty throughout the day to meet the needs of service users. Two trained nurses are available during the day. A National Vocational Qualification (NVQ) programme is in operation in the home and two staff who spoke to the inspector have achieved this award. Four further staff also have an NVQ award. One member of staff is due to finish a level three award soon and another member of staff will start their award later in the year. Staff told the inspector that they have also attended training on Alzheimer’s disease and Parkinson’s disease. An induction programme is in place to train and develop staff. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 21 Staff members stated that they felt very well supported by their colleagues and the manager of the home. The inspector examined staff training profiles and these included a record of training attended and certificates to support this record. These records did not appear to be completed properly and the inspector could not determine what training a number of staff had attended. The manager stated that the training coordinator had not completed these records fully and the administrator found some certificates in the personnel files. The manager was required to update these records to demonstrate that staff have attended all mandatory training including Food Hygiene, First Aid, Health and Safety and Moving and Handling. The manager stated that they are arranging for a First Aid training update for staff and they would ensure the records are fully updated. Five staff files were examined and found to have appropriate application forms, two or three written references, proof of identity and a completed Criminal Records Bureau (CRB) check. A clinical supervision programme has been established in the home and trained nurses are receiving regular support with a documented record of these sessions. A supervision programme is being established for carers and the inspector read the minutes of a recent staff meeting when this programme was discussed. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 22 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 Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. Service users are supported by a service, which is managed in a generally effective and open manner. Some areas need to be addressed to fully demonstrate the effectiveness of this management. The home is developing systems to ensure service users views are acknowledged and used as part of the development of the service. The home will need to address some areas of health and safety to fully demonstrate that service users are kept safe. EVIDENCE: Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 23 The manager has completed their NVQ level 4 in management and is a first level registered nurse. They transferred with the staff team from Berehill the other registered service on the site. Staff made positive comments about the level of support they receive from the manager and that they found the management of the home to be open and approachable. This was also supported by comments from care managers, service users and their families. The manager provided information and documentation to support their approach to developing a quality assurance and development plans for the service. They had decided to use a document from the Registered Nursing Homes Association as the basis for their process and the manager will be developing this over the next few months. The home has no records in place to confirm that regulation 26 visits are taking place. The manager has written up one visit by the registered owner and showed this to the inspector. The manager was advised that they should not be completing this report and it is the responsibility of the responsible individual to undertake these visits and ensure a copy of the report is available for inspection in the home. The inspector was told that the home does not keep or manage any monies for service users and that the service users need to make their own arrangements for this with their families or legal representatives. Lockable facilities are provided for service users in their rooms. One service user leaves their chequebook and card with the home for safekeeping. This is stored in a locked box and the service user has the keys to this. The home provided records to demonstrate that fire checks and tests are carried out regularly. A fire drill and practice was carried out on the 11/04/06 and all staff undertook fire training between the 14/02/06 and 16/02/06. The fire risk analysis has been completed however this is being reviewed in light of comments made by the Fire Safety Officer and the procedures for evacuating service users are being addressed. The manager has been written to by the commission and asked to respond in writing to the commission about the action they are taking to address the Fire Safety Officers comments. Staff undergo health and safety awareness training as part of their induction, food hygiene, first aid and risk assessment are included in the training programme for all staff however the manager will need to demonstrate that these courses are up to date for all staff. The home also has a general health and safety risk analysis and risk management procedure to ensure safe systems and practices are maintained. The manager said that further work is needed to provide detailed risk Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 24 assessments to support working practices. Areas identified during a tour of the premises need to be addressed by the manager include the use of bedrails, the potential risks to service users when accessing the outdoor spaces and access to the open stairwells. All windows are appropriately restricted to prevent falls. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 OP9 Regulation 13 Requirement Timescale for action 02/06/06 2 OP30 18 3 OP33 26 4 OP38 13 The registered manager must ensure that medication practices are reviewed and incorrect prescriptions are updated with the GP and pharmacist. The registered manager must 02/06/06 ensure that accurate training records are maintained to demonstrate that staff have obtained the training required to carry out their work. The registered person must 02/06/06 ensure that regulation 26 visits are carried out monthly and a report is completed for each visit and available in the home for inspection The registered manager must 02/06/06 ensure that service users are kept safe by the completion a full risk assessment for each service user that includes use of bedrails, risk of falls when using outdoor areas and open stairwells. Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 27 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 Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Wessex Lodge DS0000065491.V288406.R01.S.doc Version 5.1 Page 29 - 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!