Care Home: Albion Lodge Retirement Home

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What the care home does well The needs of people who may come to live at the home are looked at carefully to see whether the home can meet them, and the home provides sufficient information to these people. Care plans are drawn up and the health of people living at the home is promoted. People living at the home are treated with respect, their privacy and opportunities for choice maintained. There is a range of activities on offer. People living at the home considered the food to be good and there was choice available. They thought that their clothes were laundered well. Records are kept of any money that the home holds for people living at the home. People live in a clean, comfortable, homely environment. There are adequate numbers of staff on duty and a high percentage of the care staff have an NVQ qualification. What has improved since the last inspection? The manager has amended the statement of purpose, service users` guide and other documentation, following comment in the last inspection report. The paving of gravelled areas around the home was due to begin in February to improve access for people living at the home. Some aspects of the management of medication have improved. The manager and one of the deputy managers have attended safeguarding adults training. What the care home could do better: There was no evidence that people living at the home had been asked to contribute to their plan of care. The quality assurance system needed to be developed so that it was more firmly based on feedback from people living at the home and their supporters. Some aspects of the management of medication needed improvement. One of the deputy managers had not attended training in the safeguarding of adults and some staff had not updated basic training. Further risk assessments were needed to cover all areas of health and safety. CARE HOMES FOR OLDER PEOPLE Albion Lodge Retirement Home Hanley Swan Worcester Worcestershire WR8 0DN Lead Inspector Jane Morgan Key Unannounced Inspection 22nd January 2008 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 Albion Lodge Retirement Home DS0000018623.V356641.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. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albion Lodge Retirement Home Address Hanley Swan Worcester Worcestershire WR8 0DN 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) 01684 310626 darwenta@aol.com Mr Colin Darwent Mrs Jean Mary Darwent, Mr Mark Robert Darwent, Mr Andrew John Darwent, Mrs Helen Ruth Smith Mr Andrew John Darwent Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability over 65 years of age of places (36) Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate one named person under the age of 65 years. The home to be staffed as per the sample rosters and the levels are increased when necessary to meet the changing needs of the service users. 15th November 2007 Date of last inspection Brief Description of the Service: Albion Lodge is a large, detached house situated in the village of Hanley Swan in Worcestershire. The premises have been adapted and extended for their present purpose as a residential care home for older people. The property occupies a level site in a pleasant rural environment. There is ample car parking at the front and side of the building and a large well-maintained garden. The home is registered to provide care for a maximum of 36 older people who may also be physically disabled. The service users are accommodated in single rooms, all of which have an en suite facility, on three floors of the building. The majority of the bedrooms are quite spacious and meet or exceed the size specified in the National Minimum Standards. The bedrooms on the first and second floor provide attractive views of the surrounding countryside. The home has two passenger lifts to enable the service users who are accommodated on the first and second floors to access their bedrooms more easily. The communal rooms include a spacious lounge/dining room, a bar lounge, a library and a conservatory. In addition, the home provides assisted bathrooms and toilets. The home is a ‘family run’ business and has been operated successfully as a residential care home by the same family for 22 years. One of the registered providers is also responsible for the day-to-day management of the home. The fees range from £390 to £514 per week. This is taken from the information given to people thinking about coming to live at the home. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information about the home was gathered from the Annual Quality Assurance Assessment (AQAA) completed by the home’s manager, from the surveys returned by five residents, a relative and a health professional visiting the home. An unannounced visit was made to the home and our records of contact with the home since the last inspection were looked at. What the service does well: What has improved since the last inspection? What they could do better: Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 6 There was no evidence that people living at the home had been asked to contribute to their plan of care. The quality assurance system needed to be developed so that it was more firmly based on feedback from people living at the home and their supporters. Some aspects of the management of medication needed improvement. One of the deputy managers had not attended training in the safeguarding of adults and some staff had not updated basic training. Further risk assessments were needed to cover all areas of health and safety. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Albion Lodge Retirement Home DS0000018623.V356641.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 Albion Lodge Retirement Home DS0000018623.V356641.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home assesses need before people move to the home to the home, and provides information to people who may come to live at the home. EVIDENCE: The files for three residents were looked at. Two of the residents had recently come to live at the home. The home had looked at their needs and the sort of help required before they came to stay at the home. The records of the needs and help identified had not been signed or dated. The manager or senior staff visit people who are considering moving to the home before they move. People are encouraged to visit the home before making a decision about whether to live there. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 9 All five of the residents returning surveys stated that they had received enough information about the home and that they also had a contract for the services to be provided. Contracts, signed by both parties, were seen on the files looked at. Following the last inspection the home was required to make alterations to the statement of purpose and service users’ guide. These amendments have been made. Albion Lodge Retirement Home DS0000018623.V356641.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of people living at the home were set out in an individual plan of care and there was access to health care services. People living at the home were treated with respect and their privacy was maintained. The management of medication was generally satisfactory. EVIDENCE: The files looked at contained a plan for meeting the needs of the person living at the home. The plans covered such needs as mobility, continence, taking medicine, and eating. Staff were checking that the plan was still appropriate each month. The home was carrying out risk assessments for mobility, skin care and nutrition. The manager was asked about the involvement of people living at the home in drawing up care plans. He said that care plans were discussed in general terms at residents’ meetings and examples given. People living at the home had not Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 11 wished to be involved with writing them. It was recommended that a note is made on care plans that people living at the home had been asked to contribute. Four of the people returning surveys said that they always receive the care and support they needed, one said usually. Four of the people said that the staff listened and acted on what they said. One said that they did not. No further comment on this was made. The files contained clear records of visits by doctors, nurses and other health practitioners. People living at the home also had appointments for specialist services at hospitals. Four of the people returning surveys said that they always received the medical support they needed, and one said that they usually did.The relative returning a survey stated that the home “cares very well for physical wellbeing.” The deputy manager confirmed that there were no people living at the home with pressure areas. The health professional returning a survey stated that the home always seeks advice and acts upon it, and that individual health care needs are usually met by the home. A person living at the home said that there was a regular exercise session. Two of the people returning surveys commented on the difficulties in accessing the garden because of the gravelled paths. They said that gravel was hard to negotiate with a wheeled walking frame. This was discussed with the manager who stated that a landscaper going to start work on paving an area outside the library and a path round the building. There would also be two level access doors at the back of the home. This work was due to begin in February and would improve the opportunities for exercise. Medication is stored in a lockable, dedicated medication cupboard and also in a lockable medicine trolley. The home uses a monitored dosage system but with some medicine in bottles or boxes. No gaps were seen on the medicine records and variable dosages were recorded. Some handwritten medicine charts were seen. Some had two sets of initials but others did not. . The home encourages people living at the home to administer their own medication. A flow chart on self-administration was available. This was signed at the bottom as a form of consent. However, there were no specific risk assessments for each person administering their own medication. One of the files looked at contained a record of a member of staff noting that a person living at the home was becoming muddled with the administration of medication and taking appropriate steps to address this. This highlights the need for formal risk assessments which are reviewed regularly. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 12 The homely remedies list had been updated since the last inspection when the pharmacist inspector found that some of the medicines listed were not recommended for use in a care home for older people. Controlled drugs were not stored in a metal cabinet that met the Misuse of Drugs (Safe Custody) Regulations 1973. The manager said that he had not been clear what was required but that the local pharmacy would supply the correct storage. People living at the home confirmed that they were treated with respect and that their privacy was maintained. Staff induction training covered these rights. Staff were observed talking to and assisting people living at the home in a respectful, polite way. People living at the home were able to use a telephone in private and were given their mail unopened. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have opportunities to exercise choice and to participate in activities. The food provided by the home is generally good. EVIDENCE: There were routines to the daily life in the home but these were described as flexible when necessary to accommodate the needs of people living at the home. People spoken to stated that they got up and went to bed when they wished. They said that they had breakfast in bed. People living at the home were encouraged to eat lunch in the dining room. The home arranges a range of social and leisure activities. The manager said that a monthly outing was usually organised. The record showed a trip to Slimbridge in November 2007 and one to Evesham Country Park in December 2007. People spoken to mentioned exercise sessions, quizzes and the playing of musical instruments. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 14 Three of the people returning surveys said that there were always activities in which they could join, one said usually there were and one said sometimes. An additional comment was that activities were “excellent- physio, quizzes and outings”. Feedback from a relative included that more might be done to provide mental stimulation. The manager said that people living in the home were asked to participate in activities but sometimes they were poorly attended. A range of newspapers and a selection of books were available at the home. Information was available about the preferred times for visiting. People living at the home said that visitors came when they wanted to and were seen in private. People living at the home were encouraged to manage their own financial affairs. One of the files looked at held a record that a solicitor had visited. People living at the home said that they had brought personal possessions with them when they came to live at the home. The bedrooms looked at confirmed this as some contained a great many personal possessions. A record of the items brought in was kept on files. The information given to people living at the home included that they had a right to see their files. The menu displayed in the hall showed that choices were available for lunch and supper. Two of the people living at the home said that the food was “delicious” and “well presented.” They also said that they had breakfast in bed at 7.45am. Two of the people returning surveys said that they always liked the meals, two said that they usually did and one said sometimes. An additional comment was that “choice is available at every meal, vegetables are served separately and diets catered for.” Lunchtime was observed. Meals were individually served from a trolley with vegetables in a serving dish on each table. Two fresh vegetables, as well as potatoes, were offered. Assistance to cut up meat was offered discreetly. The meal was unhurried and the atmosphere chatty. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 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. 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 a visit to this service. The home addresses complaints. The home has put measures in place to protect people living at the home from abuse. EVIDENCE: The complaints procedure was amended following the last inspection to include that complaints can be referred to us at any time. The home’s complaints record contained one complaint made in June 2007. The outcome was recorded. A member of staff had been disciplined as a result. A record of this was available on the staff member’s file. No complaints about Albion Lodge have been received by us. Three of the people returning surveys said that they always know who to talk to if they are not happy, and two said that they usually did. Four said that they knew how to make a complaint, and one said that they did not. All the people living at the home who were spoken to during the visit knew how to make a complaint and were sure that any complaint would be addressed. The relative returning a survey also stated that they knew how to make a complaint. The health professional returning a survey said that the home always responded appropriately if they or a person living at the home raised concerns. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 16 The home’s policy and procedure on the protection of vulnerable adults from abuse has been amended since the last inspection. The whistle-blowing policy has also been amended to make clear that staff may refer concerns to outside regulators without exhausting internal mechanisms first. The manager confirmed that no incidents or allegations of abuse had come to his attention since the last inspection. None have been notified to us. The manager said that he and one of the deputy managers attended safeguarding adults training with other members of staff on 5/2/07. The other deputy manager said that she had not. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable, clean and homely. Laundry is appropriately managed. EVIDENCE: The home is on a level site and in a good state of repair. There was a choice of communal sitting areas including a large lounge/dining room, bar lounge and conservatory. Some handrails had been fitted in some of the corridors since the last inspection. There was a spacious garden. Comments about its accessibility have been made in the section on Health and Personal Care. The home was clean, tidy and free from unpleasant odours. The five people who returned surveys stated that the home was always fresh and clean. The Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 18 relative returning a survey also commented that the “environment is always clean and warm”. The laundry was equipped with two washing machines and three dryers. The deputy manager confirmed that the washing machines had sluicing facilities. People living at the home said that their clothes were appropriately washed and dried. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty is sufficient to meet the needs of the people currently living at the home. The home employs a high number of staff with National Vocational Qualifications (NVQ) but some basic training needs to be arranged. The evidence available indicated that the recruitment and selection of staff was satisfactory. EVIDENCE: The AQAA completed by the manager includes that there are sixteen full-time care staff employed by the home and four part-time. In the past twelve months one full-time and one part-time member of staff have left employment in the home. The manager described the staff group as very stable. The rota showed, and the deputy manager confirmed, that there were three care workers and one senior on duty in the morning. In addition a deputy manager would be on duty and, as was seen on the day of the inspection, assisted people living at the home with personal care. During the morning there would also be one or two cleaners, a cook and a kitchen assistant on duty. On the late shift there would be a senior and two care workers, a cook until 6.30pm and a cleaner. On four days of the week an additional member of staff would be on duty between 6pm and 9pm to help with baths. During the night there are two staff on duty with one person on call. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 20 Two of the people returning surveys said that staff were always available when they needed them, and three said that they usually were. The health professional returning a survey commented that “the residents are well cared for and standards are high”. The AQAA completed by the manager included the information that seventeen of the twenty three care staff have NVQ level 2 or above, with two additional staff working towards this. The files for the two most recently recruited staff were looked at. The files contained the documents specified by the care standards legislation, including Criminal Records Bureau (CRB) checks and two references. Staff files contained a contract of employment. The manager had compiled a chart showing staff training. This showed that some staff had not undertaken updated training in certain basic areas. For example, for two members of staff the last moving and handling training was recorded as March 2004 and October 2004. Another member of staff had no recorded date for moving and handling training, and another no recorded date for fire training. The health professional returning a survey expressed the opinion that staff have the right skills and experience. She commented, “staff are always courteous and helpful, and always make timely and appropriate referrals”. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is appropriately qualified and experienced. The management approach creates an open atmosphere. The quality assurance system needs to be strengthened to ensure that it is based on the views of people living at the home. Appropriate records of the money held for people living at the home are maintained. Measures are in place to promote health and safety but could be improved with additional risk assessments. EVIDENCE: Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 22 The manager, who has been associated with the home for many years, has been the manager for seven years. He completed the registered managers’ award in July 2007. People living at the home said that the manager was friendly and supportive. Staff also said that he was approachable and supportive. The health professional returning a survey commented, “the home is a happy one and a pleasure to visit”. The manager said that there is a quarterly residents’ meeting. The minutes of the meeting of September 2007 were seen. He also said that there are discussion groups every month. A staff meeting had been held in September 2007. The manager said that they were usually held twice a year. There was a quality assurance file containing the chart of staff training, an audit of staff files and a residents’ file checklist. The checklist had been completed most recently in July 2007 and January 2008. There was also a quality assurance audit completed in July 2007 which checked records for such areas as accidents, fire safety, and medication. The manager acknowledged that the request for feedback from people living at the home and other people by survey was overdue. The deputy manager stated that the home held small amounts of money for four or five people living at the home. These were locked away and held in separate amounts. The records for two of the people living at the home were checked against the amount held. The balance recorded and the sum held were the same. Receipts for payments were being kept. The home has a health and safety policy and all necessary COSHH (chemicals) and RIDDOR (accidents, incidents, infectious diseases) documentation. Accidents were being recorded. Fire records showed that the appropriate checks were being made. However, some fire doors (bedroom doors) were wedged open. Thermostatically controlled mixing valves had been fitted to the hot water taps used by people living at the home and the temperature of the hot water was being checked and recorded. Some radiators were guarded but some unguarded radiators were seen. The manager was asked for risk assessments in relation to the environment and replied that risk assessments were in residents’ files. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 23 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 2 Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 24 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 OP38 Regulation 13,18 Requirement Staff must receive training updates as necessary in core health and safety matters. (Previous timescale 31/ 12/06 not met). Timescale for action 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP3 OP9 OP9 OP9 OP18 OP19 OP33 Good Practice Recommendations The record of needs assessment should be signed and dated. The storage facility for controlled drugs should comply with the Misuse of Drugs (Safe Custody) Regulations 1973. Risk assessments should be carried out and recorded for all residents administering their own medication. The hand-written medicine charts should be checked and signed by two members of staff. The deputy manager should undertake training in safeguarding adults. Handrails should be fitted in all corridors. The quality assurance system should be further developed so that it is more firmly based upon feedback from people DS0000018623.V356641.R01.S.doc Version 5.2 Page 25 Albion Lodge Retirement Home 8. 9. 10. OP38 OP38 OP38 living at the home and their supporters. Fire doors should not be wedged open, suitable devices should be fitted to ensure closure in the event of a fire. All radiators should be guarded. Risk assessment should be drawn up for all safe working practice topics in standard 38. Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Albion Lodge Retirement Home DS0000018623.V356641.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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