Care Home: Hillfield

Similar services:

• Maple Lodge
• Heathlands
• Aston Court Nursing Home
• Breme
• Ravenhurst
• Bank House
• Inspirations
• Ashcroft Hollow Nursing Home

What the care home does well Any person considering moving into Hillfield is given assurance that the home can meet their needs; people are assessed prior to moving in and we saw evidence to confirm people are encouraged to visit the home before making any decisions. The home is kept clean and people who use the service commented on this as being important to them. There is evidence to confirm the home works in partnership with other professional bodies to ensure the best outcome is reached for the people who use the service. Communication and information exchange with all relevant parties is good. Peoples descriptions of the home were as follows: "I am very happy no complaints." "Couldn`t be nicer" "It`s lovely" The registered manager was on annual leave during this inspection but is considered approachable by people who use the service and staff alike. The home operates a person centred approach and demonstrates a very good understanding of individuals care needs. The staff receive equality and diversity training, this training reinforces the need for staff to see people as individuals with their own specific needs and wishes. Plans of care are in place for everyone, containing good levels of information for staff to meet people`s needs well, the staff are encouraged to read care plans so that they can provide the correct care and support. The home ensures staff are not employed without full employment checks therefore confirming they are suitable people to work with older people. All newly appointed staff undergo an induction programme to promote good practice, confidence and understanding in the service delivery; there is a commitment to National Vocational Qualification training for all staff. What has improved since the last inspection? No requirements were made at the last inspection held on 19th September 2006. As this is the first visit by this inspector it is difficult to record where any improvements have been made. It was clear however that the staff have kept up to date with changing legislation and are fully aware of their roles and responsibilities. The service is tailored to meet the needs of the people who use the service and updated training is offered where necessary. CARE HOMES FOR OLDER PEOPLE Hillfield Hillfield Lane Stretton Burton upon Trent Staffordshire DE13 0BW Lead Inspector Rachel Davis Key Unannounced Inspection 17th September 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000033181.V371949.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. DS0000033181.V371949.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hillfield Address Hillfield Lane Stretton Burton upon Trent Staffordshire DE13 0BW 01283 567320 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) Staffordshire County Council, Social Care and Health Directorate Mrs Philomena Palmer Care Home 36 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (36), Mental disorder, excluding learning of places disability or dementia (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (12), Old age, not falling within any other category (36), Physical disability over 65 years of age (36) DS0000033181.V371949.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3 Dementia (DE) - Both sexes minimum age 50 years on admission 1 Mental Disorder (MD) - Minimum age 45 years on admission Date of last inspection 19th September 2006 Brief Description of the Service: Hillfield is a Local Authority home able to accommodate 36 older people. The home is located in Stretton, a village on the outskirts of Burton on Trent. It is close to shops and amenities and is served by public transport. Hillfield is owned by Staffordshire County Council and operated by Staffordshire Social Care and Health Directorate. Due to major refurbishment and changes to the registration of this home admissions have not been accepted over the past twelve months. Presently there are only 16 people in residence. At the time of this key inspection the home was registered for people with dementia, a mental disorder, physical disabilities and/or old age. However, suitable aids and adaptations are being installed including the refurbishment of bedrooms and other areas because Hillfield House will soon become a home able to support 34 people with dementia related conditions. The fees for the home are £ 638:00 per week. Items not covered by the fee include hairdressing, chiropody and telephone calls. DS0000033181.V371949.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people who use this service experience good outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, national minimum standards of practice and focuses on aspects of service provision that may need further development. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent, good, adequate or poor based on findings of the inspection. Before visiting Hillfield on this inspection, survey information was sent out to the home, and the people who use the service and the staff returned a small number to us. This visit took place over one day; the staff and people who live at the home did not know we were coming. We focus on a small number of people who use the service which involves discovering individual experiences of living at the home by meeting and talking with them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. This helps us to understand the experiences of people who use the service. We look around the home to make sure that it is warm, safe, clean and comfortable. We look to see whether people who use the service are being protected and the arrangements the service has for listening to what people think about Hillfied. There were no requirements made after this visit. This means that there was nothing of significant importance that needed to be done to make sure people stayed safe and well. Our inspection reports can be obtained directly from the provider or are available on our website at www.csci.org.uk DS0000033181.V371949.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? No requirements were made at the last inspection held on 19th September 2006. As this is the first visit by this inspector it is difficult to record where any improvements have been made. DS0000033181.V371949.R01.S.doc Version 5.2 Page 7 It was clear however that the staff have kept up to date with changing legislation and are fully aware of their roles and responsibilities. The service is tailored to meet the needs of the people who use the service and updated training is offered where necessary. 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. The summary of this inspection report can be made available in other formats on request. DS0000033181.V371949.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000033181.V371949.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Hillfield delivers a professional, flexible, reliable service. Information offered will ensure people can make an informed choice about the home. EVIDENCE: The service has developed a new Statement of Purpose and Service User Guide to fit their change in registration, however it is still in draft but should be available by November 2008. The draft Statement of Purpose and Service User Guide set out the aims and objectives of the home, and contain specific information about the service, this includes the fees payable and information about other costs. Presently old copies of these documents are available in the reception hall for people at the home and visitors to look at but are outdated. Once completed a DS0000033181.V371949.R01.S.doc Version 5.2 Page 10 new Statement of Purpose and Service User Guide should be given to all the people residing at Hillfield. We recommend the home ensure they can evidence that the people who use the service do have updated and individual copies. The home is considering producing an audio and pictorial version of their Statement of Purpose and Service User Guide to help support people who use the service with complex needs. The paperwork required for admission was checked and contains the needs assessment as required, pre admission documentation is sound and offers appropriate opportunities for the home to assess whether Hillfield can meet the needs of the prospective user. It was evident the home had assessed the needs of an admitted person prior to them living at Hillfield and a subsequent plan of care has been developed; this provides staff with the information necessary to offer appropriate care. The home operates a key worker system to help individuals feel comfortable in their new surroundings; this system also helps to support people who use the service to ask any questions about life in the home and encourages the staff to develop a person centred approach to care. Standard 6 is not relevant to the home and therefore not assessed. DS0000033181.V371949.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service can be assured their needs will be met. EVIDENCE: Both plans of care seen contained detailed information to enable staff to meet people’s needs sensitively. We were able to speak with people who use the service and then cross-reference their verbal accounts with the plans of care. In both instances they tallied, this means the staff have the correct information available to deliver care in the way the individual requests. People’s care plans explain how personal care tasks are to be carried out safely and information is in place to cross-reference many aspects of the care plans with risk assessments. The care files contain a range of risk assessments, taking account of people’s personal needs and hazards associated with everyday living. In most instances care plans are being dated and signed but we recommend the people who use the service also have an opportunity to sign these plans, DS0000033181.V371949.R01.S.doc Version 5.2 Page 12 this will confirm that the people who use the service are happy with the documentation. All plans seen have been reviewed and updated, as necessary. People who use the service have access to a wide range of additional health care services according to their individual need, and assessments were in place that looked at peoples nutritional needs, continence needs, hearing and sight. This list is not exhaustive. Medication procedures were observed and are generally sound, people who use the service can be confident a safe management system is in place. On a couple of occasions staff were seen recording ‘not required’ on the Medication Administration Record chart when the medication was prescribed. This means decisions and judgements are being made by the staff members administering medicines without ensuring if this is in the best interests of the person by discussing it with their General Practitioner. We also saw that Medication Administration Sheets did not always follow their own coding system (The Key). The staff need to ensure they record information as the Key requests. We also recommend the home records both the maximum and minimum temperatures not just the average, as they do presently. This will mean the home is confident that medications are always stored within the correct temperature range. Presently where people who use the service self medicate a risk assessment is completed and these were signed by the people who use the service as required. We felt the information contained was not as explicit as it could be and we discussed this at the time of the inspection. The home must also ensure they offer and record that a lockable facility is available for the storage medication only. Records confirm the staff receive medication training which is updated as required, the manager should ensure competency checks are undertaken and recorded. DS0000033181.V371949.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 and 15. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Overall people who live in the home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs. EVIDENCE: People who use the service have the opportunity to develop and maintain important personal and family relationships. Unfortunately we did not see any visitors during this inspection so could not seek their views but the people who use confirmed they could receive visitors at any time The home verified that families and friends are encouraged to become actively involved in the life of the home if they so choose and may also attend the residents, relative meetings which are held approximately 4 times a year. Hillfield does not employ an activities coordinator, and there was little visual evidence of what activities are held within the home on a daily basis. We are confident however that activities do take place and the home does record some of these activities, further evidence would be of benefit. DS0000033181.V371949.R01.S.doc Version 5.2 Page 14 For example the staff don’t always record one to one time when they are talking to people who use the service or doing a hand massage or manicure. People who use the service offered mixed views, one person said: “ There are activities, yes, sometimes I choose to participate other times I would rather not.” Another said: “ I would like to walk around outside more, that would be lovely” When we asked the staff how they felt the home could improve they said: “ It would be nice if residents went out more.” Questionnaires returned to us asked ‘ Are there activities arranged within the home that you could take part in?’ All answered, ‘ always’. The home has a key worker system where each member of staff has specific tasks to undertake with two or three people who use the service. This promotes closer resident staff relationships where likes, dislikes and needs are shared. Key workers should use their knowledge to plan activities and update information required within risk assessments and daily living. Several people who use the service told us that the quality of the food was good and questionnaires also confirmed this to be so. People also said there was always a choice. “Its good food, you can have what you want to eat.” “The food is good, we have nice meals.” We spoke with catering staff, observed a well-managed kitchen and understand Hillfield received a 5 star rating from the Environmental Health Officer recently. The menu is not presently available (only in the kitchen), we would like to see information around the home so people who use the service can recall what they have chosen. The home should also consider the needs of the people who use the service and it may be of benefit to offer pictorial information too. The staff are sensitive to the needs of those people who find it difficult to eat and give assistance, we saw they were aware of the importance of feeding at the pace of the person, making them feel comfortable and unhurried. DS0000033181.V371949.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. People who use the service are suitably protected and their complaints are taken seriously. EVIDENCE: There have been no complaints made to us since the last inspection and the home reports that a few complaints had been made directly to the home during the same period of time. A complaints log is not kept but the staff confirmed that all complaints are recorded in the individuals plan of care. One was checked and verified the complaint have been properly recorded and followed up, indicating that complaints are taken seriously by the home. We are confident that through resident /relative meetings, reviews, staff meetings and the open door approach that people who use the service and their families are confident in the complaints procedure. The home does have an appropriate complaints procedure, but this is not easily visible and the information within it is outdated in some areas. We recommend the home ensure the complaints procedure is (for example) on a notice board or easily seen in the entrance hall. Opportunities could also become available for people to make comments discreetly via a suggestions box or comments book. DS0000033181.V371949.R01.S.doc Version 5.2 Page 16 Staff have completed training in the protection of vulnerable adults, which should enable them to safeguard people who live in the home. This was verified in a sample examination of staff training certificates and training records. Staff also confirmed they have seen the adult abuse and Whistleblowing procedures informing them how to report any suspicions of abuse or other concerns about the running of the home, should they need to do so. Systems are in place to safeguard the monies of people living in the home. The recruitment records sampled showed that a robust procedure is followed to protect people living in the home. DS0000033181.V371949.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 standard of the environment provides the people who use the service with a comfortable and homely place to live. EVIDENCE: On the day we visited Hillfield 16 people were in residence. The home is presently being refurbished and altered to accommodate 34 people with dementia related conditions. Disruption is being kept to a minimum and work should be completed by the beginning of December 2008. All people who use the service and their families have been advised of this, and new admissions will be “phased” to ensure a suitable admissions criteria is established. DS0000033181.V371949.R01.S.doc Version 5.2 Page 18 A partial tour of the building was undertaken and some people who use the service chose to show us their rooms. Bedrooms reflect personal preferences and are suitably furnished. Bathrooms provide sufficient moving and handling equipment for people who require assistance and support. People who use the service and questionnaires returned confirmed that the home is always clean and tidy. “The home is always clean.” “ It is always this way.” The home meets infection control standards, they have a policy and procedure, use soap dispensers, paper towels, protective clothing, uniforms, foot-operated bins, and have a clinical waste collection. DS0000033181.V371949.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. Recruitment procedures follow safe practice and support the need to protect vulnerable adults. All staff are suitably trained to meet the needs of the people who use the service. EVIDENCE: Two staff files examined demonstrated that a thorough recruitment practice is in place, this includes two written references, criminal record bureau checks, application forms that cover gaps in employment history, a health declaration and the required identification certificates. The home should also ensure a photograph is available on each individual staff file. Staff spoken with were very happy working at Hillfield House, they expressed their views in the following ways; “communication is good” “ it is very homely here” “we try our best to make sure the residents are well cared for.” The staff group said they: “All work as a team. ” People who use the service were also complimentary, they said: “It couldn’t be nicer” “the staff will always talk with me” and “staff are all very kind.” DS0000033181.V371949.R01.S.doc Version 5.2 Page 20 The majority of people who use the service have complex needs and these are understood and well managed by the staff team. When discussed it was clear the staff sometimes feel they may fall short in care staff numbers, especially on the afternoon shifts when 3 instead of 4 care staff may be on duty. It was revealed a high percentage of people who use the service require support from two staff (over two thirds), therefore only leaving one member of care staff on the floor to support the people who use the service. The home must be confident they can meet the needs of the people who use the service at all times, therefore staffing levels need to be under constant review. Discussions with staff and files seen identified staff appraisal sessions are lacking, this needs to be addressed without delay to help support the care staff. The management team confirmed these were starting very soon and will be covering all the required areas. All staff receive relevant training that is focussed on delivering improved outcomes for the people who use the service. The home has put a high level of importance on training and staff report that they are supported through training to meet the individual needs of people in a person centred way. DS0000033181.V371949.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. Hillfield is well managed and run in the best interests of the people who use the service. EVIDENCE: The manager Philomena Palmer is registered with us and has the required qualifications and experience necessary to run the home. On speaking with staff, analysing the Annual Quality Assurance Assessment and any returned questionnaires we feel the manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. Comments included: DS0000033181.V371949.R01.S.doc Version 5.2 Page 22 “ It’s the best environment, we work together.” “Phil is a good manager.” There is a feeling of warmth and openness in the home and overall staff deliver good care. People who were spoken to were happy with the manager and staff team and felt they were approachable. Staff have completed fire training including regular fire drills. All people who use the service have an individual evacuation plan incase of fire. The home needs to identify a ‘safe haven’ and record this place within their risk assessment or policy. We have also asked the home to ensure the storage of their wheelchairs under the stairs is suitable and safe. The annual quality assurance assessment (AQAA) is a legal document that all services have to complete on a yearly basis. All sections of the AQAA were completed and the information gave us a reasonable picture of the situation within the service. The evidence to support the comments made is satisfactory, although there are areas where more supporting evidence would have been useful to illustrate what the service has done or how it is planning to improve. This is because the AQAA only gave us limited detail about the areas where they still need to improve and the ways that they were planning to achieve this is sometimes only briefly explained. Monies were checked and all records and receipts tallied, people who use the service can be confident their allowances are stored and managed suitably. DS0000033181.V371949.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 3 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 2 17 X 18 3 3 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 2 DS0000033181.V371949.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP1 Good Practice Recommendations When the new Service User Guide is available the home should ensure all people who use the service receive a copy in a language and format appropriate to their needs. This means that people have the information readily available to assist them in making an informed choice. Plans of care should be developed to include people who use the services signatures where possible. This means there is evidence to confirm people who use the service have had involvement in developing their own plan of care. A record of the maximum and minimum temperature of medication stored in the fridge should be recorded. This will ensure medications are always stored within the correct temperature range. The home should consider ways to monitor competency around medication practices. This will assist in ensuring a safe service is continually promoted. DS0000033181.V371949.R01.S.doc Version 5.2 Page 25 2 OP7 3 OP9 4 OP9 5 OP9 6 7 OP15 OP16 8 9 10 11 12 OP16 OP27 OP29 OP38 OP38 The Medication Administration Sheets should offer exact information as per the homes medication policy and guidelines, this means an audit trail is available at all times if required. We recommend the home ensure the menu is available to the people who use the service. The home should consider the introduction of a suggestions box and/or comments book so people who use the service and visitors are offered the opportunity to raise their views anonymously if they so choose. The complaints procedure should be easily visible, for example on a notice board or hung from the wall. The home should keep staffing levels under constant review to ensure they can meet the needs of the people who use the service. All staff files should include a recent photograph. The home should contact the fire officer to ensure the storage of wheelchairs under the stairs is considered safe practice. The home must identify a ‘safe haven’ for people who use the service in the event of a fire and necessary full evacuation. DS0000033181.V371949.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000033181.V371949.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. 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!