Care Home: Sydenham

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What the care home does well What has improved since the last inspection? The care staff have undertaken a great deal of training since the last inspection to include diabetes, first-aid, medication, health and safety and are currently undertaking dementia training. An appraisal and supervision programme is now in place, as is a quality assurance programme. What the care home could do better: The home has a medication procedure in place but must ensure that out of date medication is returned to the pharmacist promptly and dressings prescribed for one resident are not used for others. Recruitment procedures are in place but the application process is to be reviewed and issues identified in the report addressed. Satisfaction surveys have been completed and a report compiled as part of the quality assurance programme but no action plan has been developed to confirm that suggestions have been acted upon and improvements made. CARE HOMES FOR OLDER PEOPLE Sydenham High Street Blakeney Glos GL15 4EB Lead Inspector Mrs Janet Griffiths Key Unannounced Inspection 8th August 2007 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 Sydenham DS0000016596.V342679.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. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sydenham Address High Street Blakeney Glos GL15 4EB 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) 01594 517015 Mrs Lyn Nussey Mrs Tina Jane Gibson Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2006 Brief Description of the Service: Sydenham House is situated on the western edge of Blakeney village on the A48 in Gloucestershire. The house is Victorian and has been adapted to accommodate 19 elderly people who require personal care. Much has been done over the years to improve the physical standards in and around the home. A large comfortable conservatory has been added in recent years, which offers residents an additional communal area to the large lounge/dining room that is also available. The majority of rooms have en suite facilities, although there is an assisted bath on each floor for those frailer residents. With the exception of two shared rooms, the home offers all single accommodation. Each room is very tastefully and individually decorated and many are furnished with items of residents’ own furniture and personal items creating a very ‘homely’ atmosphere. The home has a shaft lift that serves all floors in the home. Information about the service to include CSCI reports is made available by the provider to prospective service users through the homes’ Statement of Purpose and Service Users Guide. At the time of inspection the fees are between £350 and £400 per week. Additional charges are made for hairdressing, chiropody, newspapers and magazines and transport for social purposes. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection site visit took place over nine hours on two days in August 2007. During this time the inspector spoke to a number of residents, three relatives, staff working in the home and the manager and provider of the home. A tour of the premises took place. All of the bedrooms and communal areas were seen during the course of the two days. Four resident’s files were examined in detail to include their medication records. Other records examined included staff recruitment and training records, quality assurance surveys and accident records. Surveys were sent to service users prior to the inspection and the results were collated and fed-back at the end of the inspection. An Annual Quality Assurance Assessment (AQAA) was sent out several weeks before the inspection and returned to CSCI. Information from this was used when completing the site visit and writing the report. What the service does well: The home is a small family run establishment and as such manages to maintain a comfortable, homely environment. The standards of décor and furnishings are excellent. The home has a well- motivated staff team, who all love the work they do and are all very committed to training and development and providing a good quality of care for the residents. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sydenham DS0000016596.V342679.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 Sydenham DS0000016596.V342679.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): 1,2 and 3. Standard 6 not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families have all the information they need to make an informed choice regarding placement at the home and pre-admission visits take place to carry out an assessment and ensure that needs can be met. New admissions are often on a trial basis. Residents normally move in on a long-term basis therefore Std. 6 was not assessed. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home has a comprehensive Statement of Purpose, and a Service Users Guide, a copy of which is given to each resident/ their relatives on admission and is kept in the resident’s room. This is reviewed regularly, last being June 2007, and any changes made. A slight amendment is required to change references to National Care Standards Commission (NCSC) to Commission for Social Care Inspection (CSCI). From surveys received, all but one confirmed they had been given enough information about the home prior to admission and several confirmed that they had either visited the home before admission, come to stay on a short trial basis or were originally visiting the home for day care. Three relatives were spoken with; one said how happy they were with the home and the standards of care provided. Their relative had settled in extremely well and was very happy in the home; one said that their relative was still settling in and having changed rooms since admission there were still a ‘few touches’ required within the room to make them feel more at home; a third said that their mother had made the decision to come in on a trial basis themselves and was very happy with that decision. There were contracts in all of the records seen outlining all the required information, to include fees. Most were signed; one was waiting to be returned having been signed by a relative. All of the surveys received, with one exception, said they had received a contract (in that instance it was explained that a relative had probably signed it). The manager or proprietor always sees each prospective resident and carries out an assessment. This ensures that the home would be able to meet their needs. This is fully recorded and examples of pre-admission assessments were seen. Sydenham DS0000016596.V342679.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. People who live in this home have their health care needs met through individually planned care that clearly set out needs and how they are met, to include healthcare referrals and interventions where required. They are also protected by the medication administration procedures that the home has in place and are treated with respect; their privacy and dignity are protected. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 11 EVIDENCE: Four care files were examined in detail to include those of residents admitted since the last inspection. All were fully assessed and from this, individual care needs and how they should be met, were clearly identified. All seen reflected the current needs of the resident. These are reviewed regularly with the residents/relative where possible and signed by them. Staff spoken with demonstrated that they were fully aware of all of the resident’s needs and how they could meet them. They are kept informed on a day- to -day basis by the handovers at each shift change. Resident’s surveys and those residents spoken with also confirmed that they felt their needs were met, as did two of the relatives spoken with. When asked if they receive the care and support they need, the responses were all positive, some stating the following: ‘I enjoy it at this home. I get on very well with carers and I also enjoy the food’. ‘ Both staff and doctors have all been great’. Residents and staff spoken with, and the care records, all confirmed referral and intervention from health professionals where necessary. The local general practice is a short distance from the home and doctors visit as required or the residents go to see them. The same applies to the practice nurse for health screening such as blood pressure checks, weights and blood tests. Several residents are currently receiving attention from the district nurse and one receives daily Insulin injections from them. Residents also confirmed that they had received chiropody and an optician and dentist visit as required. One resident has been assessed by the District Nursing Service as being vulnerable and a hospital bed with pressure relieving mattress and a chair cushion have been supplied, as has a hoist, as this resident requires mechanical assistance with moving and handling procedures. The home states in its Residents Charter within the service users guide that ‘they are treated with respect and dignity at all times’; ‘that they may lead as full and independent a life as possible within the privacy and security of the home’ and are able to ‘live their lives free from discrimination, regardless of race, sex, religion and disability’. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 12 Residents spoke with confirmed this and observations showed residents being addressed respectfully, and staff knocking on doors before entering rooms. It was noted in the records seen that preferred form of address was recorded. Residents may have locks/key pads to their doors if they wish and a lockable drawer and a safe are provided in each room. The medication system within the home has greatly improved over the last two years with the introduction of individual locked medication cupboards in each room. Each resident has their medication administered from their own cupboard. All staff who administer medicines have received training in the use of this system of administration. Medication records, together with the medicines were examined and were well maintained. Medicines are dispensed by the local general practice. The home has very recently experienced some problems with an incorrect dosage of tablets being kept in a box labelled with the correct dose. This was identified when that resident was admitted to hospital. The proprietor has met with the practice manager who is carrying out an investigation and a report is to be written and a copy forwarded to the Commission. As a result of this a full audit of all the medication was carried out to check that the tablets inside the labelled packets are correct. During the inspection of medications it was noted that one room had a container of aqueous cream with the expiry date 2/07 and another room had a supply of dressings for another named resident. These were to be followed up. One resident has insulin injections administered by the district nurse, who keeps her own records. However, in the event that this resident is transferred to hospital during the night it should be recorded on his medication chart that he is on insulin together with a note of his most recent blood sugar level. Sydenham DS0000016596.V342679.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 who live in the home are supported to realise their own preferences and expectations, both in the home and in the community and are able to maintain contact with friends and family. They also receive a wholesome, appealing and balanced diet in pleasant and comfortable surroundings. EVIDENCE: New notice boards in reception and in the dining room display among other things, a programme of activities which includes entertainers, bingo, dominoes, sherry evenings, coffee mornings every Friday morning, shop Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 14 (where they can buy a variety of things to include greetings cards) and film club. The hairdresser visits twice a week and also provides manicures for the resident which they greatly enjoy. One resident said: ‘I like having my hair done once a week and a perm when I need it. I also have my nails manicured’. One resident is very independent and talked about going out to local bingo games and about his successes at these. He also makes use of his bus pass to visit local places and enjoys helping out in the garden. Other residents go out quite regularly with their relatives and several relatives come in to the home and help their parents with bathing and other tasks. One lady was busy knitting a thick warm scarf and was selling these recently at the homes’ summer fete. Reportedly all the staff have one. She said she enjoys doing this as its something to do and keeps her fingers active. A communion service is held at the home once a month and during the summer months out door services are held, weather permitting. Visitors are welcomed. One stated in a survey: ‘I am very grateful to the staff at Sydenham House for the care they have given to my mother’. Daily menus are displayed in the dining room and reception and are changed regularly to offer variety. Individual preferences are well known and alternatives are offered. On the first day of the inspection roast beef and all the trimmings or a ham salad were offered and on the second day shepherds pie. All the food seen looked appetising and well presented. Once a month the local church prepares ploughman’s lunches and a sweet, which are delivered to the home and one resident reported how much they had enjoyed fish and chips from the local fish and chip shop earlier that week. All of the surveys and residents spoken with confirmed that they were generally happy with the food provided, with the following comments made: ‘I shall have to soon cut short some of the food. I am putting on weight, so that I can still wear the dresses and such like when I was nineteen’. and ‘The food is lovely’. Sydenham DS0000016596.V342679.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in the home are protected by the systems in place. EVIDENCE: The home has a complaints procedure included in the service users guide and displayed in reception. One minor amendment is required to change any reference to National Care Standards Commission to the Commission for Social Care Inspection. Surveys received all confirmed that they would know how to complain and who to speak to if they were unhappy. A records of complaints received was seen. The home has policies on abuse and whistle blowing. They refer to the document ‘No Secrets’ and the Alerter’s Guide (which is displayed on the notice board in the dining room). Staff had also all received training on Protection of Vulnerable Adults, confirmed by the certificates seen in their files. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well maintained, clean and hygienic throughout. Individual bedrooms are decorated and equipped to meet the needs of their occupants. EVIDENCE: All of the resident’s rooms and the communal rooms were visited during the inspection. Several residents were spoken with in their rooms. Individual bedrooms seen, reflected the interests and needs of their occupants. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 17 Some residents had brought in favourite items of their furniture such as a chair and there were lots of photographs, pictures and ornaments in many of the rooms seen. However the needs of those who preferred minimal decoration was also respected. One resident had moved from an upper floor room to a ground floor room for safety (because of the stairs) since admission and speaking to his wife she was concerned that his room now looked bare and was hoping to bring in several more items of furniture from home to make it feel more homely. The proprietor explained that they needed to discuss this with the family as too much furniture may be considered a risk to his mobility, but a compromise would be met. All areas of the home were clean and odour free Everywhere was well maintained and in good decorative order. Just one or two small areas such as a window- sill requiring painting and a toilet seat to be fitted were reported and are to be addressed. A list of all the work undertaken in 06-07 was provided for the inspection and includes redecoration of the stairwell and first floor landing, replacing all the door handles, redecorating and refurbishment of the top floor bathroom and providing a new roof and fascia for the building. Several beds and carpets have also been replaced and the dining room/lounge carpet professionally cleaned. One carpet was about to be cleaned. The residents spoken with were all happy with their rooms, several commenting on how they enjoyed the views either of the busy road and village life, or the local school and the activities of the children. The surveys completed confirmed that the home was always fresh and clean, with one stating: ‘The standards of cleaning and laundry are excellent’. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home have their needs met by sufficient skilled staff who are able to meet the needs of the current number of people living at the home. They are also protected by the homes recruitment system. Staff are supported to undertake regular and relevant training. EVIDENCE: On the two days of inspection, the manager, one carer, one domestic and the proprietor were on-duty to care for seventeen residents. Two residents were in hospital. Either the manager or proprietor are generally responsible for preparing all the meals. There is one ‘waking’ night staff but the proprietor who lives across the road is on call from 10 pm. There was a calm unhurried atmosphere in the home and no one appeared to be under pressure and no residents were observed calling or waiting for attention. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 19 All the surveys received confirmed that staff were usually available when needed and always listen to what they have to say. One did however make the comment: ‘The staff are all very caring but with often only 2 carers on-duty and only one at night I feel they are overstretched’. There have been several new staff appointed since the last inspection but only one carer who was considered satisfactory and remained past the probationary period. One member of staff also resigned following suspension for investigation of verbal abuse. The Commission was kept informed throughout this process. A selection of staff files, to include that of the one new member of staff, were examined during the inspection. All had an application completed but several amendments were required to this; at present a full career history with dates in order to explore gaps is not present and although staff complete a medical questionnaire, confirmation of mental and physical fitness is absent; there is also no written request for two references, one being the last employer although with one exception all had this in place, the proprietor stated that she automatically contacts the last employer. One did not have any references on file and this was being followed up. All staff have had Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks and all of these were seen. The manager was advised that once seen by CSCI these can be shredded in accordance with Data Protection. Induction training records were seen. There are four members of staff with NVQ level 2, one with NVQ 1 in cleaning and the manager is half way through the registered Manager’s award. A printout of all the recent training completed was provided for the inspection. Individual staff training records were also seen with certification to confirm recent training completed over the last year which includes moving and handling, violence and aggression in the workplace, safe methods in the kitchen, nutrition in care homes, safe handling of medicines, health and safety, personal safety awareness, protection of vulnerable adults and dementia training. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33,35, 36,37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home have their best interests met by the proprietor and manager who are committed to their responsibilities. They and the staff are protected by the health and safety systems in place in the home. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager is currently half way through the registered Manager’s award and together with the proprietor who has day- to- day control of the home, is competent and experienced to run the home. Since studying for the RMA she has been delegated a lot more responsibilities, which the proprietor formerly dealt with and stated that she is enjoying the course although she will be having a new tutor shortly. As the home is quite small with a small workforce, they meet every day to discuss anything relevant to the home and the people who live there. Meetings are held occasionally but these have not had an agenda or been minuted and there have been none recently. Records of staff supervision and annual appraisals were seen. The home has carried out several surveys recently, their aim being to complete four a year dealing with a different topic on each occasion, for example Christmas and resident’s rooms. These have been collated and a report written, given to the inspector at inspection, but no action plan has been developed. The results seen so far have been very positive with remarks such as: ‘Christmas was very enjoyable, the staff are very good and help in any way. I am very happy’. ‘I decorated my room with cards and Graham and Ben did well with the decorations’. Regarding their rooms: ‘I enjoy watching the children play’ and when asked about spending time in their rooms, ‘Sometimes I enjoy some privacy’. Residents finances are their own or their families responsibility and the home does not act as appointee to any resident. Every room has a small safe and residents may keep whatever they want in there for security. Records were seen to confirm that regular maintenance and servicing of equipment is carried out, to include electrical wiring and portable appliance testing, gas, lift and hoist servicing. Fire equipment is also serviced regularly (on the day of inspection) and fire alarms and emergency lighting tested regularly. Staff also receive fire training, which records confirmed. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement Ensure the arrangements for recording, handling, safekeeping, safe administration and disposal of medicines received into the home in relation to prompt disposal and use of prescribed dressings for others residents. Ensure that all relevant checks and records are completed and satisfactory prior to the appointment of a new member of staff. Timescale for action 30/09/07 2 OP29 19(1) 30/09/07 3 OP33 24 30/09/07 The registered person should maintain an effective quality assurance and quality monitoring system for the home, reviewing at appropriate intervals and improving. Timescale of 31/07/06 not met in full in relation to development of an action plan. Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 24 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 Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Sydenham DS0000016596.V342679.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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