CARE HOMES FOR OLDER PEOPLE
Aquarius Nursing and Residential Care Home 4 Spencer Road Southsea Portsmouth Hampshire PO4 9RN Lead Inspector
Jan Everitt Unannounced Inspection 28th September 2005 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 Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 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. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Aquarius Nursing and Residential Care Home Address 4 Spencer Road Southsea Portsmouth Hampshire PO4 9RN (023) 92 811824 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) Qualitycare Management Limited Mr Ronald Charles Biddle Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (38), Old age, not falling within any other category (38), Terminally ill over 65 years of age (26) Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Staffing notices apply Date of last inspection 27 April 2005. Brief Description of the Service: The Aquarius Nursing Home is a care home providing nursing care for 38 older people over the age of 65 years who suffer from mental frailty, mental disorder, excluding learning disabilities. The home is also registered to accommodate 26 older people with life limiting diseases. The Aquarius is the only care home owned by Quality Care Management Ltd. The home is located in a residential area of Southsea, close to the sea front and the local amenities of the city of Portsmouth. The home consists of three large houses that have been joined together to the effect of a large town house. The service user accommodation is located over three floors. There is a pleasant courtyard at the front of the house and a patio area at the rear for service users to use in the finer weather. Nine of the eighteen single bedrooms have en-suite facilities. There are ten double rooms seven of which have en-suite facilities. There is a passenger lift fitted from the ground floor to the first floor only. Chair lifts are in place on some of the other flights of stairs that access other floors. Rooms that have been identified as having only access via a flight of stairs can only accommodate service users who are fully mobile. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection of the Aquarius Nursing Home took place on the 28th September 2005. This was the second inspection for the year 2005/6 and was undertaken by the inspector and the regulation manager Mr. A. McMullen. Mrs. Lightwood, the responsible individual, Mrs. Lin, personal assistant to Mrs. Lightwood and Mr. Challoner, the acting manager assisted the inspectors throughout the inspection. The process took five hours. 17 standards were assessed, five of which concluded the 20 core standards to be assessed in this year. The remaining twelve standards were identified as needing assessment as requirements had arisen from them as the result of the previous inspection. Of the 17 standards assessed, 11 had been met and 6 had minor short falls. The standards that have remained unmet and have been highlighted in the requirement section have been discussed with Mrs. Lightwood and timescales negotiated. As the result of a complaint received in July 2005, the inspector visited the home with the Hampshire Fire and Rescue Service officers who identified a number of short falls in the fire safety of the home. Mrs. Lightwood has worked with the recommendations made by the HFRS and has complied with the recommendations they stipulated. The complaint has subsequently been resolved. Since the inspection of the 27 April 2005, and the subsequent meeting with Mrs. Lightwood and the home’s management team at the CSCI offices, the management have worked consistently throughout the past five months to comply with the requirements and recommendations made at the last inspection, at which time serious concerns were raised with regards to standards of practice within the home. Service users were spoken with at this inspection at various times of the day and they reported satisfaction with the care in the home and their environment. Due to the mental frailty of quite a number of the service users it was not always possible for the inspectors to gain accurate information and their opinions about the care provision in the home. What the service does well:
The staff care for a group of services users with high dependency of complex needs. Observation of service users and their general appearance, that of being clean and well presented, would suggest their physical needs are being met. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 6 The home strives to include relative/friends in the planning of care for the service users who are unable to advocate for themselves. Care plans are reviewed monthly. The food is well-presented and nutritious in content and service users report they enjoy the menus and also that there is alternative food available if they request it. Staff are available to help those who needs assistance with eating. The staff interact well with the service users and are familiar with their likes and dislikes. The atmosphere of the home was more positive and relaxed and staff were observed not to be rushing about but taking time with service users. The home is clean and free from any odours. The PA to the responsible individual (RI) audits the cleanliness and the maintenance of the home regularly. The home is making efforts to maintain a regular redecoration programme as a room is vacated. What has improved since the last inspection?
A new care planning system has been introduced which centralises all the information and planned care for the service user into one file and should result in information about the service user and their care being more available to staff to inform their practice. There has been three new assisted baths installed and one bathroom is in the process of being converted into a large shower room. The home is now meeting the standards in this respect. There is ongoing maintenance within the home and various areas of the home have been redecorated and new furniture purchased. A number of adjustable beds have been purchased and will gradually replace the old divan beds. The recommendations made by Hampshire Fire and Rescue Services officers, to upgrade the fire safety system have been complied with. Locks on the fire exit doors have been repositioned to a more appropriate level and the gates removed from the front entrance. Thermostats have been placed on all hot water outlets including the basins in all bedrooms. The various notices displayed around the home with regards to policies within the home have been removed and the house now looks more homely. All confidential and judgement information about the service users has been removed from the office wipe board and this information is now contained in the care plans. The five-year electrical check has now been completed and a certificate issued, a copy of which is on the home file. A training matrix has been created by the PA of the home to identify training needs. The home is striving to maintain safe staffing levels. Snacks are available for service users throughout the 24-hour period and the home ensures that no more than 12 hours is between service users taking diet and fluids.
Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 7 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. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 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 Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1. Standard 6 is not applicable to this home. The prospective service users and their relatives do not receive all the information about the home to make an informed decision about living in the home. EVIDENCE: The home has a Statement of Purpose that is placed in every service user’s room. The Service User Guide is not available and this was discussed with the Responsible Individual (RI), who reported that this has been reviewed and was at the printers at the time of this inspection. A requirement for this was raised at the previous inspection and will be a requirement of this inspection. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 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 & 10 The service user’s health and social care needs are set out in individual plans of care which need to be developed further. Service users are treated with respect and their rights and privacy upheld. EVIDENCE: A new care planning system is in the process of being developed by the acting manager. It has centralised all the information about the service user and their needs and planned care to meet the needs. Although further development is needed of this system, it should make information more available to staff in one file and give them information on how to care for that person. The inspector viewed a sample of 5 service user’s care plans and records. The care plan details the required information about the service user as stated in Schedule 3 of the Care Home Regulations. The care plans were evidenced as being reviewed monthly. There was no evidence that nutritional assessments are undertaken routinely but weights are recorded at regular intervals for service users who are considered at risk. A recommendation will be made from these findings. Tissue viability risk assessments were evidenced on all care plans audited. Those identified of ‘at risk’ did not have a descriptive care
Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 11 plan to guide practice, although the inspector did observe a large number of pressure relieving mattresses in use on beds. This was discussed with the senior nurse and a recommendation will be made from these findings. The inspector observed that locks were not fitted to bedroom doors. This has been discussed in previous reports. The Service User Guide needs to state that service users are given the choice of having a lock fitted to their door on admission to the home, following the appropriate risk assessment. Staff were observed to be interacting well with the service users and treating them kindly and with respect. Access to a private phone for service users to make and receive calls was discussed with the RI as this had been a requirement from the previous inspection. She reported that there are only two service users who use the phone, one of which is for incoming calls from abroad. The other service user can use the office phone and receive calls on this phone in private. This phone line is a separate one from the one used by administration. The RI reported that if, as service users are admitted and they request the use of a phone, she will ensure that a public phone is installed in an appropriate area. The inspectors observed that all notices and information displayed about the home and confidential information about the service users capabilities, highlighted in the previous report, have been removed and such information is contained in care plans. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 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 & 15 The home was meeting the social and recreational needs and expectations of the service user client group to the potential that their mental frailty would allow. Service users receive an appealing, wholesome diet in pleasant surroundings. EVIDENCE: The home does not employ an activities organiser and the care staff, sometimes on a one to one base, undertake activities. The home does attempt to obtain information about the social history and past interests of the service user, but the RI reports that this is not always relevant to their present mental frailty. An outside entertainer attends the home to play music and service users are invited to participate with their own instruments supplied by the home. The staff were observed to be interacting well with the service users and the atmosphere of the home was calm and unhurried. Service users spoken with expressed their satisfaction and appeared content within their daily activities. Many of the service users, because of their mental frailty, were unable to communicate or express opinions to the inspection. A number of the service users were mobile and were observed to be busy walking around the home independently.
Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 13 The inspector observed the lunchtime meal being served. The meal was wholesome and presented well. Service users reported to the inspector that they enjoyed their meals. There was no alternative choice advertised at lunchtime, but several service users were observed to be having alternative meals and reported to the inspector that it was of their choice and at their request. The inspector observed that service users who were in need of assistance were being fed appropriately and in a respectful unhurried manner with good interaction taking place between carer and service user whilst this took place. The tables were laid appropriately and most service users chose to eat at the tables and appeared to be enjoying the meal in a relaxed atmosphere. At the time of this inspection there were sufficient staff during this period to meet the needs of the service users. The RI reported that the three meals are spread out throughout the day with supper of a milky drink and biscuits offered at 2000 hrs, thus ensuring that there are no more than twelve hours between the last meal of the day and breakfast time the next morning. The staff have access to the kitchen throughout the night should a snack or drink be requested by a service user. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 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): These standards were not assessed on this occasion. EVIDENCE: Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 15 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, 24, 25 & 26 Service users live in a safe, well-maintained environment. Service users have sufficient lavatories, washing and assisted bathing facilities to meet their needs. Service users’ bedrooms are comfortable and furnished appropriately. The home is clean and hygienic. EVIDENCE: The inspectors toured the building. The home has undergone an extensive programme of maintenance work that was highlighted from the previous inspection and the requirements made from that report have now been complied with. The fire integrity of the home has also been improved since the inspection of 1st August 2005, when the Hampshire Fire and Rescue Officer made a number of recommendations. These recommendations have been complied with. The home now has five assisted bathing facilities and all hot water outlets are thermostatically controlled. The water temperatures are tested randomly on a
Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 16 weekly rota and records are maintained. The inspector tested the hot water temperature and it was found to be within safe parameters. The fitting of domestic type lighting in the rooms identified as having fluorescent lighting must be programmed into the maintenance programme for the coming year. This will be a requirement of this inspection report. The home was observed to be clean and homely. A separate domestic staff is employed throughout the week to maintain standards. The inspector observed that new furniture has been purchased in areas of the home to replace old furniture in disrepair. The RI reported that she is purchasing nursing beds as and when the divan beds needs to be replaced. A number of new armchairs have been purchased for the lounge areas. Staff were observed to be wearing aprons and gloves and these were observed to be readily available in each service user’s room. All radiators throughout the home have now been fitted with covers, which are cosmetically pleasing but allow access to the thermostats that control the heat of the radiator. The laundry was not visited on this occasion. The RI reports that the plans for the extended dining facilities and the new kitchen and laundry have been passed by the local council and work on this will commence next spring. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 17 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, 29 & 30 Service users’ needs were being met at the time of the inspection by the number of staff and skill mix. The homes recruitment policy and practices continue to need improving to fully protect the service users. Staff are trained appropriately to do their job. EVIDENCE: The inspector viewed the duty rotas for two weeks. These showed that two trained nurses and five carers are on duty all day with one trained and three carers at night. This was discussed with the RI with regards to sufficient staff for the dependency of the client base. From observation of the routine of the day of the inspection being unhurried, staff having time to talk to service users and interact with them and discussion with staff in general, it would suggest that sufficient staff are on duty. The inspector recommended to the RI that this staffing level be kept under constant review and must reflect the changing dependency of the service users. The home has an induction programme in place. The inspector viewed a completed programme that had been signed by the participant as having taken place. Mandatory training takes place within the home some of which is undertaken by an outside training provider. A training matrix has been produced to identify staff that need updating in mandatory health and safety issues. The training matrix recorded that moving and handling, infection control, first aid; fire safety, basic food hygiene and abuse are subjects that
Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 18 are included in the mandatory training. Certificates of attendance were seen in the staff files. The inspector observed some gaps in the updating of training and this was discussed. The home is working towards 50 of their carers having NVQ level 2. 5 staff have NVQ level 2 and a further four are undertaking NVQ level 3. A sample of recruitment files was viewed. The acting manager’s file was viewed and there still remains the outstanding requirement to obtain two written references, one from her most recent employer. There is no evidence in this file of an application form. These issues were discussed with the RI, who reports that these issues are in the process of being resolved. A requirement will be made from these findings. Recruitment practices were discussed with the RI and the inspector advised her that CRB checks are not portable within the care industry and she must take up a POVA and CRB check for all new staff. The inspector reiterated to the RI that references must be applied for and received before employment commences and that there must be evidence that the home has requested references. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 19 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): 33, 35,36 & 38 The home does not have a quality assurance system for all systems within the home. Service users financial interests are protected. Recorded supervision does not take place for all staff. The health and safety and welfare of service users and staff are promoted and protected. EVIDENCE: The home does not have a quality assurance system in place to monitor the practices and systems within the home. The personal assistant to the RI monitors the housekeeping systems regularly and this is documented. There was no evidence of care plan and clinical practice audits. Questionnaires are distributed to service users and relatives and an analysis is undertaken to
Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 20 identify areas of improvement and good practice. The CSCI does not receive regular Regulation 26 reports from the nominated person visiting the home monthly to monitor the quality issues. A requirement will be made. The policies and procedures of the home need to be reviewed imminently to guide the practices within the home. This was a requirement of the last inspection. The RI reports that the acting manager is in the process of reviewing all policies. These will be viewed at the next inspection. Two Hampshire Fire and Rescue Service (HFRS) officers attended the home on 1 August 2005 following a complaint to inspect the fire integrity of the building. They made a considerable number of recommendations to improve the fire safety of the building. The RI has complied with all the recommendations and has kept both HFRS and the CSCI informed as the work has been completed. The fire officers are to make a visit to the home to ensure compliance. The inspector viewed the fire logbook and all appropriate tests of the systems are recorded. The personal assistant to the RI ensures that all new staff are fully conversed with the fire procedure and reports that it forms a large part of the initial induction programme. The five-year electrical wiring certificate has now been issued and a copy forwarded to the CSCI. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 21 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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X 3 X X 3 2 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 3 Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 22 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 OP1 Regulation Requirement Timescale for action 15/12/05 2 OP25 3 OP29 Reg A Service User Guide must be 5(1)(2)(3) made available for all potential service users and/or their relatives. A copy of this document must be submitted to the CSCI with the stated timescales. The timescale of 30/6/05 was not met. Reg. You are required to fit domestic 23(2)(p) type lighting in bedrooms identified as having fluorescent lights fitted in them. This was a requirement of the last three inspection reports and discussion with the CSCI has resulted in this being agreed to be part of the maintenance programme to be completed within the next 6 months. The timescale of 30/6/05 was not met. Reg.19(1) You are required to ensure that (b)(i)Sch all information required to be 2 obtained and stated in Sch. 2 of the Care Home Regulations is obtained during the recruitment process and contained in personnel files. Two written references and evidence of CRB
DS0000011470.V249805.R01.S.doc 30/04/06 30/11/05 Aquarius Nursing and Residential Care Home Version 5.0 Page 23 4 OP33 Reg 24 (1)(a)(b) (2) and POVA checks must be sought before employment commences. You are required to complete the recruitment process for the acting manager should she take up a permanent post. The previous timescale of 6/6/05 was not met. A quality assurance system must 31/12/05 be put in place to monitor the standards within the home. The policies and procedures that guide practices in the home must be reviewed to reflect new and updated practices. Monthly reports must be sent to the CSCI with the outcomes of the visit by the registered provider or nominated person who undertakes these visits. You are required to ensure that persons working at the care home receive formal supervision at least 6 times per year and records of this taking place, be maintained. A plan of how this will be actioned is to be returned to the CSCI within the stated timescales. 30/11/05 5 OP33 Reg 26 6 OP36 Reg 18(2) 30/11/05 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 OP7 Good Practice Recommendations It is strongly recommended that the new care planning system be developed further to include care plans for those service users who have been identified as being ‘at risk’ from breakdown of tissue. It is strongly recommended that all service users’
DS0000011470.V249805.R01.S.doc Version 5.0 Page 24 2 OP7 Aquarius Nursing and Residential Care Home nutritional status is risk assessed and those identified of being ‘at risk’ have detailed care plans detailing a proactive strategy for prevention and monitoring. Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Aquarius Nursing and Residential Care Home DS0000011470.V249805.R01.S.doc Version 5.0 Page 26 - 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!
