Inspection on 20/06/06 for Washington Grange

This inspection was carried out on 20th June 2006.

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

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

Other inspections for this house

Washington Grange 22/05/08

Washington Grange 30/05/07

Washington Grange 27/09/05

Washington Grange 05/05/05

Washington Grange 21/12/04

Washington Grange 17/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Washington Grange Burnhope Road Barmston Washington NE38 8HZ Lead Inspector Mrs Elsie Allnutt Key Unannounced Inspection 20th June 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Washington Grange DS0000054917.V299122.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. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Washington Grange Address Burnhope Road Barmston Washington NE38 8HZ 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) 0191 419 1955 0191 417 0100 washingtongrange@barchester.com Barchester Healthcare Lynda Errington Care Home 40 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (19) of places Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Washington Grange owned by Barchester Healthcare Limited is a purpose-built care home situated on the edge of the Barmston housing estate in Washington. The home is close to a local health centre, pharmacy and a social club. A short walk to the nearest bus stop provides access to the Galleries shopping centre and all its amenities, Sunderland City centre and to other parts of the surrounding areas. The home is a two-storey building offering single bedrooms with en-suite facilities that are easily reached by a passenger lift and stairways. There are 19 bedrooms for older people on the ground floor and 21 bedrooms for older people with dementia care needs on the first floor. There is a range of bathrooms and showers, WCs, lounges and dining rooms on both floors. All parts of the building are easily reached. This home has developed a comprehensive Statement of Purpose and Service User Guide that informs people of the aims and objectives of the service. These are made available in the entrance to the home. The range of the current fees for this home are between £346-£442 per week. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 9.5 hours during one day in June 2006. The views of service users and relatives were sought prior the inspection and the overall view was that the care and support provided in the home was satisfactory. 4 out of 10 service users felt that the service provided was “always satisfactory” and 6 out of 10 felt that it was “usually” satisfactory. 2 people felt that there was only “sometimes” enough activity going on. When talking with the service users many made complimentary comments about the staff and their attitudes. However 2 service users said that some of the staffs’ attitudes could be “nasty.” This was brought to the attention of the manager. A tour of the building was made as well as an examination of a number of records. Six of the ten staff on duty during the day and twelve of the thirty-six service users and three visitors were spoken to. What the service does well: What has improved since the last inspection? Not all of the issues identified in the last inspection report have been addressed, but those that have, have resulted in the following improvements to the home. Service users’ care plans have been developed further and now include individual care plans in relation to service users’ medical needs. This means Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 6 that staff are guided to address issues around, for example, diabetes and the way it relates to the individual service user. So that individual service users medicines do not get mixed up and given to the wrong person, all medicines received from the pharmacist are now labelled and includes the service user’s name and the date the medicine was issued. Complaints to the home are now addressed and recorded appropriately following the home’s Complaints Procedure. This means that service users and other parties can be assured that complaints are taken seriously. 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. Washington Grange DS0000054917.V299122.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 Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,6 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. A range of information is available which enables service users to make a fully informed choice about where they would like to live. However not all staff are fully equipped to deal with issues relating to the care provided by the home. This could result in service users not receiving appropriate care. The admissions process ensures that service user’s needs are assessed prior to care being offered. This enables service users to be offered the right type of care at the home. EVIDENCE: A Statement of Purpose and Service User Guide are in place to inform service users and other interested parties about the home and the services offered. Both documents have been reviewed and updated so that the information provided is current. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 9 The manager ensures that an assessment of need and current care plan for the individual prospective service user is received from the referring agency and that the home carries out their own assessment prior to any service user being offered a place. Once it is determined that individual needs can be met by the home the manager confirms this in writing to the service user. A date is then set for admission into the home. Three case files confirmed that this process is carried out appropriately and as an outcome the home has developed individual care plans. However the care files identified that service users living at this home have Parkinson’s disease and diabetes and not all staff could confirm that they had attended training in relation to these. Neither could the manager and a member of staff who was working on the dementia unit confirm that they had attended training relating to dementia. A discussion about the importance of having appropriately trained staff took place with the manager and it was agreed that any member of staff with responsibilities of being in charge of the home at any time, or who are working in the dementia unit, must attend training in relation to dementia issues as a matter of priority. This home does not provide intermediate care. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Generally the healthcare needs of the service users are met while at the same time their dignity and rights are protected. However, further improvements can be made to ensure that staff understand and appropriately use the new care plan document so that it is used effectively as a working tool. Medication administration procedures ensure that the service users’ health care needs are addressed. EVIDENCE: All of the service users living at this home have a care plan in place. However the home is currently transferring the care plans into a new document, developed by the company. The manager confirmed that she had received training in relation to this. As the transfer to the new system is still in the early stages it is initially being used for service users who have recently moved into the home. As part of the sample of care records examined two were of the new style. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 11 The structure has been developed to cover all areas of care that the company provides including some relating to nursing care. Although this home does not deliver nursing care the individual documents relating to this have not been removed. For example in one service user’s file who is independent and does not have any nursing needs, Wound Assessment Chart, Anticoagulant Therapy Chart, Blood Pressure Chart and Neurological Observation Charts were included. These charts were designed to be used by nursing staff only and are causing confusion to the staff who have been directed by the manager to transfer the old care plans into the new system. This was discussed with the manager who agreed that she must monitor the use of the plans and guide her staff how to use them appropriately by using only the parts that the service users living at this home need. A care file that had not been transferred to the new system and belonging to a service user with Parkinson’s disease was also examined. This clearly demonstrated that the needs of the service user were addressed appropriately. Assessments and care plans in relation to mobility, falls, pressure sores, nutrition and self-medication were in place. Risk assessments were also in place to support these needs and to guide staff to reduce any risk involved as a result of the condition. The service user confirmed that they were aware of the plan of care and commented favourably how their key member of staff supported them. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are offered the opportunity of participating in a range of leisure and social activities enabling them to lead active and fulfilled lives, and are offered a choice of nutritious meals, to help promote their health and general well being. EVIDENCE: There was a good atmosphere in the home that was lead by enthusiastic staff, some of who were dressed up in red and white to support the England football team, who were to play that evening in the World Cup. Service users responded favourably to the staffs’ efforts and they took part in different activities that were going on throughout the home. A small group of service users played dominoes in the lounge, while others listened to music. A member of staff spent some time chatting with a service user sitting on their own. Many of the ladies were delighted to discuss their visit to the hairdresser who was busy on the first floor cutting, washing and setting a number of service users’ hair. This event was well organised and the room resembled the activity of a small hairdressing salon. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 13 A member of staff confirmed that the home attempts to get people out into the local community as much as possible. One service user confirmed that they had enjoyed a short walk prior to lunchtime and another discussed their visit to the local shops. A local community group was using the home’s dining room for their weekly game of bingo, as the room in the community that they usually use was not available. Although no service users were taking part in this activity, one service user was watching. Visitors were observed coming and going to the home throughout the day. One relative confirmed that they were always made to feel welcome. Service users confirmed that they make choices in relation to their lives. They also confirmed that they can manage their own finances if they wish, and there is a locked facility in their room if they chose to do this, or they can keep their money in the home’s safe and withdraw it when necessary. The administrator confirmed this and demonstrated how appropriate accounts of financial transactions were satisfactorily kept. A meal was taken with the service users at lunchtime that was both tasty and nutritious. Service users confirmed that this was an example of the meals generally served. The manager discussed a new training programme that has been developed by the company for kitchen staff in relation to providing nutritious food. Advice and guidance is being given from a celebrity chef. So that service users have an opportunity to access support when making decisions in their lives, information relating to an independent Advocacy Service is available. This is advertised on a notice board in the entrance hallway. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a satisfactory complaints procedure that is now being used appropriately. Attempts are therefore made to protect service users from being at risk. Service users are protected by the home’s Protection of Vulnerable Adults (POVA) procedures, however the attitude of some staff can sometimes be construed by service users as offensive. EVIDENCE: The home has a procedure to record complaints and service users and their relatives were confident they could use this. The Complaints Book was examined. No further complaints had been logged since the last inspection. The home follows the local authorities procedures relating to the Protection of Vulnerable Adults (POVA). Staff confirmed that not all had attended training in relation to these. So that all staff have a good understanding of issues surrounding abuse and the steps they need to take if abuse is observed, heard or reported to them, they must attend the local authorities training. Although the majority of service users confirmed that the attitude of staff towards them was caring and respectful, two service users remarked that staff were generally “nice” but some were “nasty.” Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 15 This was discussed with the manager who is currently investigating the matter and has agreed to inform CSCI of the outcome. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. So that the quality of the original high standards of the environment is maintained, and the service users enjoy comfortable and safe surroundings that promotes their dignity and self esteem, the home is in need of redecorating and refurbishment. The current bathroom facilities do not offer a choice of bathing facilities. EVIDENCE: The cleanliness of the home reflects the home’s effective cleaning routines. A new member of the domestic staff confirmed that she had shadowed a more experienced staff member before being left to carry out the cleaning duties alone. All staff have attended training in relation to infection control. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 17 The manager confirmed that the new laundry system recently implemented and which protects service users and staff from the possibility of cross infection continues to work well All areas of the home inspected were clean and tidy. The handyperson was on holiday at the time, but the manager confirmed that the day-to-day maintenance issues continue to be addressed appropriately. A squeaking door that was disturbing a service user, who was trying to rest in the quiet of their room, was reported to the manager who agreed to sort it out. As found at previous inspections the original high standard of décor and furnishings generally are now showing signs of wear and tear. However the easy chairs in the lounge on the ground floor have now been replaced and these now provide more comfort for service users. There was a noticeable shortage of small tables for service users to put their drinks on in the lounge but the manager confirmed that new tables had been on order for some time. One area of the home has had a carpet replaced in response to a health and safety issue. This carpet does not blend in with other carpets or matches the current décor. The manager confirmed that there are plans to decorate throughout the building but she was not aware of the date for this to start. Neither was she aware of the details of the refurbishments planned for the dementia unit that is particularly showing signs of wear and tear. A discussion took place with the manager in relation to the importance of seeking professional advice in relation to what colours and designs to use to promote the wellbeing and orientation of people with dementia. The manager confirmed that this issue was being addressed. Although there are an adequate number of bathrooms in the home they all do not meet the needs of the service users or give choice of bathing facilities. As all service users using this service now need assisted bathing facilities this issue is currently being addressed. Since the last inspection both bathrooms on the first floor have been equipped with lifting equipment so there are now adequate assisted bathing facilities on this floor. The ground floor however still only has one bathroom where there is lifting equipment. The manager stated that there are plans to make a shower room on the ground floor so that service users have a choice of bathing facilities. However there are no dates for the plans to commence. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The majority of the staff team are qualified to meet the needs of the service users and are competent to carry out their role effectively. However not all staff have received the necessary training to respond to challenging situations in a professional way. There is a risk therefore of service users’ needs not being fully met and that they might feel insulted by staff. The staffing levels remain inadequate therefore there is a risk that service users needs will not be fully met and that they may not be in safe hands at all times. EVIDENCE: Staff were observed working with enthusiasm and interacting with service users in a warm, respectful way. However although most service users stated “staff are friendly” and “helpful,” two stated, “some staff can be nasty.” When investigated further, this comment related to an incident that is currently being investigated and that took place a few days earlier. However when discussing the issue with staff they accepted that the attitude of some staff might sound “off hand” at times. This is unacceptable and all staff must learn to address service users in a polite and respectful way even when the situation can be challenging. This was discussed with the manager who agreed to address the issue. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 19 Although some members of staff have worked at this home for many years there has been a high turnover of staff in the home over the past 12 months. The issue relating to inadequate staffing numbers at the home remains a concern, although one member of staff felt that the staffing numbers had improved. This concern has been raised in the past two inspection reports. The manager stated that extra staffing resources had been acquired by increasing the part time hours of one member of staff, however the same member of staff was then transferred to another home and since March 2006 these hours have remained unfilled. The staffing ratio therefore remains inadequate. Observations made and comments made by staff, confirmed that this situation has a particular negative effect in the dementia unit where more staff are needed to address the needs of the service users. At the last inspection comments were made in relation to senior staff working long hours to cover a vacant senior post. In response to a Requirement made in the report this post was filled, however due to maternity leave in March 2006 the post became vacant, resulting in senior staff again working long hours to cover the vacant shifts. Staff spoken to and records confirmed that training opportunities appropriate to individual staff’s role continues to be offered. However, so that all staff have the knowledge and understanding of their role, they must attend training related to the specialist needs of service users for example dementia and diabetes and the kitchen assistant must attend Basic Food Hygiene training. Three staff recruitment files were examined and all included appropriate application forms, two written references and CRB checks. However a negative comment on one reference that had not been checked out, was brought to the attention of the manager, who agreed that she has responsibilities to address such situations. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The manager is supported in her role by a supportive senior management team, effective administrative staff and systems, and a well-equipped staff team, all of which promotes the health, safety and welfare of the service users. However the manager fails to address some of the responsibilities of her role, as a result of this service users could be put at risk. EVIDENCE: The Registered Manager for this home has been the manager for the past 2.5 years and is now qualified, having successfully completed the Registered Managers Award (RMA) and NVQ 4 in Care. However at times during this inspection the manager failed to demonstrate her awareness and understanding of the responsibilities related to her role. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 21 This was discussed with the Clinical Nurse Manager for the home following the inspection. Many of the requirements of the previous report have not been addressed, neither was the manager aware of what stage the home was at in relation to these. Although many management tasks are delegated to senior staff the manager must be aware of the issues surrounding them. The Deputy Manager is responsible for the formal supervision of all staff. A sample of these records was examined. All were up to date and appropriately recorded. The manager stated that she was unaware of the issues raised during such sessions, as supervision sessions were confidential between the member of staff and the Deputy Manager. It was suggested to the manager that she should be aware of issues raised so that she can develop individual training and personal development plans and use these in relation to the development of the service provided. The manager was advised to read and increase her awareness of the responsibilities accepted as a Registered Manager and as explained in the Department of Health’s Care Homes for Older People National Minimum Standards and the Care Homes’ Regulations 2001. Washington Grange DS0000054917.V299122.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 X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 2 29 30 X 2 2 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 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Washington Grange DS0000054917.V299122.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 OP4 Regulation 12(1) Requirement The Registered Manager and staff must receive training to equip them with the skills and experience to deliver the services and care which the home offers to provide, in particular dementia, Parkinson’s disease and diabetes. Any member of staff with responsibilities of being in charge of the home at any time, or who are working in the dementia unit, must attend training in relation to dementia issues as a matter of priority. The Registered Manager must monitor the use of the new care plan structure and guide her staff how to use them appropriately, making sure that all relevant information is included. 31/08/06 Timescale for action 30/09/06 10(3) 2 OP7 OP32 15(1) 12(1) 3 OP7 15(1) The Registered Manager must 31/08/06 make sure that the care plan only includes information relating to the care provided by the home. Monitoring and DS0000054917.V299122.R01.S.doc Version 5.2 Page 24 Washington Grange observation charts, designed for the use by nursing staff should only be used by nursing staff and should not be part of the home’s care plan. 4. OP4 12 & 15 & 16(2)(i ) Service users with special dietary 31/08/06 needs must have a care plan related to these and all care plans should include a list of food likes and dislikes. Care must be taken so that staff serve service users the food that reflects their special dietary need. (Timescale of 30/11/05 not met.) Training arrangements must be made for all staff who have not yet attended training in relation to the local authority’s Protection of Vulnerable Adult (POVA) procedures. (Timescale of 30/11/05 not met.) 31/08/06 5. OP18 13(6) 6 OP18 12(1)(5) The Registered Manager must 31/07/06 guide and direct the staff team to communicate in a way that is appropriate to service users individual needs, as well as being respectful. So that the quality of the original high standards of the environment is maintained, and the service users enjoy comfortable and safe surroundings that promote their dignity and self-esteem, the redecorating and refurbishment programme must continue. (Timescale of 31/03/06 not met) 31/12/06 7 OP19 23(2) OP31 12(1) The Registered Manager must be aware of the timescales involved. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 25 8 OP27 OP38 18 (1)(a) So that senior staff can carry out 31/08/06 their role effectively within reasonable hours, the Registered Manager must address the senior staff vacancy. So that the needs of the service users are effectively met the staffing ratios and the allocation of staff in the home must be reviewed. (Timescale of 29.07.05 & 30/11/05 not met ) 31/08/06 9 OP38 OP27 18(1)(a) 10 OP29 OP38 19(1) 11 OP31 12 OP31 The Registered Manager must make sure that any discrepancies found on staff application forms must be followed up to ensure that the best interests of the service users are protected. 10(3) The Registered Manager must up date her knowledge, skills and competence in relation to the needs of the service users, in particular in relation to issues related to Dementia and Diabetes. 9(1)(2)(3) The Registered Manager must raise her awareness of the responsibilities that go with her role. 31/07/06 31/10/06 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP21 Good Practice Recommendations Consideration should be given to how the current bathroom facilities can meet the full needs of the service users on the ground floor. The Registered Manager should make sure that the DS0000054917.V299122.R01.S.doc Version 5.2 Page 26 2 OP30 Washington Grange OP8 information pack, designed to guide staff in relation to issues around diabetes and discussed at the last inspection with the Clinical Nurse Manager, is put into practice. Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Washington Grange DS0000054917.V299122.R01.S.doc Version 5.2 Page 28 - 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!