CARE HOMES FOR OLDER PEOPLE
Birds Hill 25 Birds Hill Road Poole Dorset BH15 2QJ Lead Inspector
Debra Jones Unannounced Inspection 23rd January 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 DS0000020510.V279881.R01.S.doc Version 5.1 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. DS0000020510.V279881.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Birds Hill Address 25 Birds Hill Road Poole Dorset BH15 2QJ 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) 01202 671111 01202 660808 matronirdshill.co.uk Mr B Seewooruthun Mrs S Seewooruthun, Mr R Seewooruthun, Miss S Seewooruthun Mrs Soussan Seewooruthun Care Home 72 Category(ies) of Dementia - over 65 years of age (26), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (26), Old age, not falling within any other category (46) DS0000020510.V279881.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The Merlin and Starling units may accommodate a maximum of 46 persons who require general nursing care The Nightingale unit may accommodate a maximum of 26 persons who require mental nursing care 5th May 2005 Date of last inspection Brief Description of the Service: Birds Hill cares for 72 older people in a purpose built care home. It is set on a hill near the town centre and Poole General Hospital. The home is on four floors, with the three upper floors being used for the accommodation of the residents. There are two passenger lifts to all levels. Each floor houses a different unit. Nightingale is on the 1st floor, Merlin is on the 2nd and Starling is on the 3rd. Nightlingale is the unit which is home to the residents with mental health problems and dementia. There is a variety of aids and adaptations around the building to allow residents to move about more independently. There are two double bedrooms on each floor. The rest of the bedrooms are single. Most of the rooms have ensuite facilities and there are communal bathrooms and toilets on each floor. DS0000020510.V279881.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours. The inspection was the second of the two anticipated inspections of the year. Debra Jones and Judith Bracewell undertook the inspection. Requirements and recommendations made at the last inspection were followed up. Inspectors looked around the building and at a range of records kept by the home. Shan Seewooruthun represented the management of the home and assisted inspectors in their work on the day. In addition staff on duty and a number of the residents were spoken to. Prior to the inspection a number of comment cards were sent out by the home on behalf of the Commission. Of those returned 10 were from residents, 1 from a care manager, 1 from a Doctor’s surgery and 13 from relatives / visitors. Most comment cards returned were positive about the staff and service provided at the home. Comments included the following :‘Staff have professional cheerful attitude and are kindness itself in dealing with all patients.’ ‘Everyone looks after nan extremely well.’ Out of the 9 residents who returned comment cards 6 said that they liked living at the home and felt well cared for, while 3 said that this was the case for them ‘sometimes’. What the service does well:
A calm and relaxed atmosphere has been created for the residents to live in. The home is well maintained, well decorated, well furnished and very clean and fresh smelling. The home is owned and run by the Seewooruthun family who have a very hands on approach to the management of the home. Residents benefit from their availability, their understanding of care and their ongoing investment in the home. Community health professionals support the home staff in caring for residents. DS0000020510.V279881.R01.S.doc Version 5.1 Page 6 Staff were observed throughout the inspection to be treating residents with courtesy and kindness and most residents confirmed that their privacy and dignity were respected. Visitors are always welcome at the home and residents are encouraged to maintain and develop relationships with people in the home, with their families and friends and the local community. A choice of meals is always available. The dining rooms are pleasant and comfortable. The majority of staff at the home have qualifications in care and caring. In addition to the nurses working at the home there are care assistants who have trained as nurses in other countries and are looking to work as nurses in this country. This means that residents are well looked after in respect of their health and general care needs. What has improved since the last inspection? What they could do better:
The statement of purpose is due for revision and needs to include more information about the services provided in the home especially the specialist mental health service that is delivered on Nightingale unit. By improving this information potential residents, relatives and placing authorities will have a better understanding of what the home can offer and if it will suit their needs. The home needs to make sure that people know that the statement of purpose and service user guide are available on request and that they can also have a copy of the last CSCI inspection report if they want to. Care plans should be more holistic in content and be clear about how staff are to meet all needs e.g. not just physical care needs. Risk assessments could also be broader in content and need to have clear plans in place when risks are identified.
DS0000020510.V279881.R01.S.doc Version 5.1 Page 7 The home should place a greater emphasis on meeting the social and leisure needs and preferences of residents to improve the quality of their daily life. Activities at the home should be based around the interests and hobbies of residents. Ensuring that residents’ general choices and preferences are being respected is an area that the home needs to look at from time to time to make sure they are getting it right for the individuals living at the home. Choices and preferences need to be built into care plans to make sure that staff are aware of them and act on the residents wishes. Staff need to be reminded of how best to assist residents when they are eating. The home should regularly look at their menus to check that residents are getting sufficient fruit and vegetables. It would be good if there were always fruit and fruit juices on the units. The home management should be regularly consulting with residents about what they would like to see on menus. The home is not yet keeping their staff records in accordance with the law. For example not all staff have completed a Criminal Record Bureau check, or been checked against the Department of Health Protection of Vulnerable adults list, and not all files contain proof of the persons identity. While these checks and documents are not complete residents are potentially at risk of having unsuitable staff working with them at the home. It would be good if the written recruitment policy / procedure was expanded to include all the things the home actually does, and needs to do, before employing people at the home. One unit in the home is just for people with mental health needs / dementia. The majority of staff who work on this unit have had training to work with this resident group but there are some who regularly work there who have not. It would be good if all staff working with people who have mental health needs and dementia had specialist training to ensure that they have a real understanding of the needs of residents and how to meet them. The home needs to survey all parties who might have views on the home and ask them how it might be made better for the people living there. Such people might include relatives and friends of residents, health professionals and care managers. Once complete a report should be compiled and an action plan to address the results of the surveys be developed. The home needs to carry out a review of their policies and procedures and in so doing ensure that they reflect the actual practice in the home e.g. the recruitment procedure; and at others to ensure that they are really clear in the message they are giving to staff e.g. the adult protection policy. Policies and procedures are important in that they underpin the practice of the home and give staff direction in how they are to do things for the good of the residents. DS0000020510.V279881.R01.S.doc Version 5.1 Page 8 Staff say that they are well supported at the home. Evidence was seen of supervision taking place but records did not show what was discussed at the sessions and just recorded training dates. Regular discussions about care practices with individual members of staff results in standards of residents’ care staying high. All records required to be kept by law must be kept. This includes the need for the home to have a recent photograph of every resident. 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. DS0000020510.V279881.R01.S.doc Version 5.1 Page 9 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 DS0000020510.V279881.R01.S.doc Version 5.1 Page 10 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): 2 (standard 6 is not applicable to this home) The home’s statement of purpose and service user guide, although pretty comprehensive, does not include details of the specialist mental health service available on Nightingale unit. Also prospective residents are not routinely made aware of the availability of the guide, statement of purpose and last inspection report. These shortfalls may result in prospective residents not having sufficient information to make an informed decision about moving into the home. EVIDENCE: The statement of purpose and service user guide contains all the information required by law and suggested by the Department of Health in the minimum standards. The statement of purpose has not been recently reviewed and does not give specific information about the services delivered at the home e.g. the specialist mental health service delivered on Nightingale unit. The home also has a brochure for the home which is given out to any people making enquiries about Birds Hill. The service user guide is not routinely given
DS0000020510.V279881.R01.S.doc Version 5.1 Page 11 out to residents and it is not clear in the brochure that the guide, the last inspection report and the statement of purpose are available on request. Pre admission assessments are carried out for all prospective residents. These contain a range of essential information about the person. However, they do not say who carried out the assessment, how or where the assessment took place, or where the information contained in the assessment came from. They also do not include the rationale for the decision as to where the person is to be placed within the home e.g. explaining why a person whose primary need appears to be dementia is placed on a general nursing unit rather than the dementia unit. This is not to say that any residents are currently inappropriately placed. DS0000020510.V279881.R01.S.doc Version 5.1 Page 12 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 and 10. The care planning system in place is designed to make sure that staff have the information they need to meet the needs of the residents but the lack of information about how to meet social and psychological needs potentially leave some aspects of residents’ needs unmet. The health needs of the residents are met with evidence of good support from community health professionals. Most residents confirmed that they were treated with dignity and that their privacy was respected. EVIDENCE: Care plans were sampled for a number of people on the different units, some care plans related to people the Inspectors talked with and others were for people who had recently moved to the home. A range of assessments were on files to inform the plans. Such assessments included self care, personal risk, falls, continence, nutrition, physical health, behaviour, lifting and handling. Care plans included sleep preferences.
DS0000020510.V279881.R01.S.doc Version 5.1 Page 13 Information was seen about people’s social histories. In respect of social care needs files sampled referred to the need for the home to ‘promote and maintain the social and psychological well being of residents’ and for daily living to be ‘mentally stimulating’ but the care plans did not contain information about how the home was going to achieve this for specific individuals e.g. how they were going to incorporate previous and current interests and hobbies. Information about how people like to spend their days was not seen. Throughout the home there are people with confusion, dementia and mental health problems. From time to time residents display behaviour which could be described as challenging. Assessments and daily notes document examples of this but there were no individual plans as to how staff are to assist specific individuals or any reference to specific interventions that staff had found effective for individuals. Daily notes are kept. These focus on the personal and physical care delivered e.g. catheter care. Aside from ‘giving reassurance’ no examples were seen of how staff were delivering dementia / mental health care. Useful information was displayed on the walls of the nursing stations on the units. Photographs of how one resident was to be helped with occupational therapy exercises. There was no mention in the notes seen that staff had done these exercises with the resident. There was evidence of reviews of assessments and plans taking place. Many residents have equipment e.g. mobility / pressure relieving mattresses / bed rails etc. Risk assessments were seen but not all those seen had been reviewed recently. Not all assessments made it clear why equipment was actually needed e.g. one resident had bed rails. The assessment merely said that they had mental health problems and a history of falls. Risk assessments were generally limited to equipment and did not cover the wider risks that need to be considered to ensure the safety of residents. Some residents have call bells in their rooms and others do not. Where residents are not able to use their call bell this was covered in the risk assessment. However, alternative methods as to how they are to alert staff to emergencies or how staff are to increase their monitoring of such residents were not documented. There was evidence of community health professionals visiting residents at the home including GPs, chiropodists and occupational therapists. During the inspection staff spoke to residents with appropriate friendly tones of voice and were seen to treat residents with dignity and respect.
DS0000020510.V279881.R01.S.doc Version 5.1 Page 14 One member of staff talked of how she was new to the country and had only worked in hospital settings before. She said the importance of treating people with dignity and respecting their privacy was new to her and was an area that the home’s induction programme had stressed. One resident said that staff did not always knock on her door before entering. Of the 9 residents who returned comment cards prior to the inspection 8 said they felt their privacy was respected and one said this was the case ‘sometimes’. Standard 9 will be fully assessed by the Commission’s pharmacy inspector at a separate visit. DS0000020510.V279881.R01.S.doc Version 5.1 Page 15 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 and 15 Social activities available in the home are not planned around the assessed needs of individual residents. Visitors are made welcome at the home and can come whenever it suits the residents. More could be done to ensure that residents are helped and encouraged to exercise choice in their daily lives at the home. A menu is offered that provides a choice of meals, though assistance provided does not always best meet the needs of the individual. EVIDENCE: During the inspection inspectors chatted with residents in the communal areas and in their rooms to get a feel for what it is like to live at the home. In the morning there are no structured activities. In the afternoon there was a concerted effort by staff to engage residents in activities in the lounge and residents were enjoying a game of catch.
DS0000020510.V279881.R01.S.doc Version 5.1 Page 16 Interactions between residents and staff appeared generally positive. It was clear that the majority of residents really responded well when staff approached them. Each unit has an ‘activities book’ in which daily activities that the residents are involved in are kept. Activities listed include reading magazines, playing with shapes and looking at pictures of ‘friendly animals’, playing and listening to the piano and writing on the ‘magic slate’, drawing and puzzles. The activities book also recorded visitors. An entertainer comes to the home once in a while and a representative from the Roman Catholic Church visits monthly for communion. Not all residents were listed in the activities book. Residents spoke of how they spend their days. One did not like using the lounge and spent all day in her room watching TV and doing jigsaw puzzles. One resident sat in the lounge said that there was nothing to do and they would like to do quizzes. Another resident said that she would like to paint. Of the 9 residents who returned comment cards 6 said the home provided suitable activities with the other three saying that they did ‘sometimes’. As stated above (standard 7) care plans do not outline how residents are to have their specific social needs met at the home. Residents talked of their families visiting. The visitors book held in reception further evidences the range and number of visitors to the home. As noted elsewhere in this report some references are made to personal preferences in care plans and assessments. The statement of purpose / service user guide says that residents have the right to choose when they go to bed and when they get up. Some residents said that they were happy with the time they got up in the morning. One said that she felt a bit rushed by the carers when she was getting dressed. Another said that she had no choice about what time she went to bed and got up. Staff said that the night staff got most people up before the end of their shift at 8am and that day staff got most people to bed before the end of their shift at 8pm. On another unit another member of staff said that when they came on duty at 8am there were still some residents in bed who don’t want to get up too early in the morning and their choice was respected. A high number of daily notes sampled showed that people were getting up at 6.30am. Night staff make and serve the breakfast on the units. Lists of the special dietary needs of residents are readily available in the nursing stations. The chef was also knowledgeable about who needed to eat what. Special diets currently catered for include diabetic and gluten free.
DS0000020510.V279881.R01.S.doc Version 5.1 Page 17 There is always a choice of meal at lunch and in the evening. The menu is displayed on the board in the dining rooms of the units. This changes each week and is on a four-week cycle. One unit was displaying the menu of the previous week. There is a pleasant dining room on each unit at the home. Few residents eat in the dining rooms. Some residents need staff to help them eat. Not all members of staff lowered themselves to the same level as the residents when they were feeding them. One resident had to tilt her head back to accommodate the position of the member of staff feeding her. It was good to see interaction between residents and the staff feeding them. The chef keeps records of what people select to eat and of the temperatures of the food that is served. The current gap between the evening meal and breakfast is over 12 hours. Food is available on each unit for snacks for residents. Diabetics are routinely given a snack in the evening, usually sandwiches. One diabetic said he was bored with always eating sandwiches and sometimes had cereal instead. During the inspection inspectors chatted with residents about food and reported back their ideas for change / improvement to the management. Such suggestions included having fruit always available on units, having fruit juices on units - not just the already diluted fruit drink, having more chicken on the menu, having a wider range of vegetables. Menus seen did not demonstrate that residents were getting 5 portions of fruit and vegetables a day. Of the 9 residents who returned comment cards 6 said liked the food at the home with the other three saying that they liked it ‘sometimes’. DS0000020510.V279881.R01.S.doc Version 5.1 Page 18 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): Standards 16, 17 and 18 were met at the last inspection. EVIDENCE: None of these standards were assessed on this occasion. DS0000020510.V279881.R01.S.doc Version 5.1 Page 19 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): All of these standards were met at the last inspection. EVIDENCE: None of these standards were assessed on this occasion. DS0000020510.V279881.R01.S.doc Version 5.1 Page 20 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): 28, 29 and 30 (Standard 27 was met at the last inspection) Staff are trained and well qualified but both residents and staff would benefit from staff undergoing a broader range of training to ensure that the care needs of residents can be understood and met. Appropriate documentation required by law is not yet in place for all staff thereby failing to offer full protection to residents from potentially unsuitable workers being employed at the home. EVIDENCE: Birds Hill is recognised by the Nursing and Midwifery Council to undertake adaptation courses to enable nurses from overseas to register in this country. Prior to completing the course the candidates are employed in the home as health care assistants. This means that the calibre of the staff in respect of their knowledge and nursing experience is high. Staff files are kept for all the people working at the home. A thorough recruitment process is in place and files showed that staff completed application forms, were interviewed and where staff were from overseas appropriate work permits and visas were in place. However, some documents, required by law, were missing from the staff files sampled. Not all files had proof of the person’s identification; some did not have CRB (criminal record bureau) disclosure certificates, or proofs of checks against the POVA (Protection of Vulnerable Adults) list.
DS0000020510.V279881.R01.S.doc Version 5.1 Page 21 The home has a written recruitment policy / procedure but it is very brief and does not cover the full processes that the home should go through before appointing any staff. At the last inspection it was noted that training at the home was good but that whilst some staff had had training in dementia this did not include all those employed on the specialist mental health unit – Nightingale. Not all staff on this unit have had training about mental health either. The home is currently looking at distance learning and at local university courses for the qualified staff. Dementia is covered at induction but no information was available on the day of inspection as to what was actually covered and the time spent on this particular topic. All qualified staff that work on the specialist dementia unit have qualifications appropriate to their work. DS0000020510.V279881.R01.S.doc Version 5.1 Page 22 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, 37 and 38 (Standards 31, 32 and 35 were met at the last inspection) The full quality assurance system has not been fully implemented yet this year which would demonstrate that the home is taking into account the views expressed by residents and other stakeholders in the running of the home. Supervision records do not currently demonstrate that sessions cover all the aspects of practice necessary to ensure that the care of residents’ remains at a high level. Fuller records of fire drills are now made and fire training is at an adequate regularity to ensure that residents are offered the best protection possible in the event of a fire. DS0000020510.V279881.R01.S.doc Version 5.1 Page 23 EVIDENCE: A formal quality assurance system is in place. The responses to the annual survey received earlier this year showed that residents were generally happy with the home in respect of care, staff, management and facilities. Residents and staff can also make suggestions at any time through the use of the suggestion box. A report of this year’s quality assurance activity is yet to be compiled. Policies and procedures were last noted as being reviewed in 2004. Supervision records show the training that staff have had but do not demonstrate that the sessions have covered all aspects or practice, philosophy of care in the home and career development needs. Records of fire drills now contain more detail of how the drill was conducted and how effectively staff responded to it. Fire training records were satisfactory. All records requested were made available. Not all files contained a recent photograph of the resident. DS0000020510.V279881.R01.S.doc Version 5.1 Page 24 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x 2 2 3 DS0000020510.V279881.R01.S.doc Version 5.1 Page 25 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 4 • Requirement Timescale for action 01/04/06 2. OP7 15 The statement of purpose should be reviewed and more detailed information must be included about the services which are to be provided by the registered person for residents e.g. the service delivered on the specialist mental health unit Nightingale. • All residents and prospective residents should be made aware of the availability of the service user guide, the last inspection report and the statement of purpose for the home. (Previous timescale of 01/10/05) • Care plans must include how 01/04/06 the home is to meet the individual social and psychological needs of each resident. Plans must be based on past and current interests, hobbies and preferences. • Plans must also be clear about how staff are to address behaviour and which interventions work with
DS0000020510.V279881.R01.S.doc Version 5.1 Page 26 3. OP7 13 4. OP12 16 5. OP29 19 6. OP33 24 7. OP37 17 particular individuals. Daily notes must evidence this in practice. • Risk assessments must cover the full range of risks residents may experience and where assessments lead to the use of equipment this must be clear. • Risk assessments must be regularly reviewed. • Where call bells are not in use alternative emergency alert / monitoring systems must be in place, documented and reviewed regularly. The registered person must consult residents about their social interests and about the programme of activities arranged at the home and provide facilities for recreation including, having regard to the needs of the residents, activities in relation to recreation, fitness and training. All staff records required by law must be held on file i.e. proof of identification, CRB disclosures and POVA and POVA first checks. (Previous timescale of 31/10/04) The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the home, including the quality of nursing. The registered person shall supply to the Commission a report in respect of the quality review and make a copy of the report available to residents. All records required by law must be kept. This includes a photograph of all residents. 01/04/06 01/04/06 01/04/06 01/04/06 01/04/06 DS0000020510.V279881.R01.S.doc Version 5.1 Page 27 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 OP3 Good Practice Recommendations It is recommended that it be routinely noted on pre admission assessments who carried out the assessment, how or where the assessment took place, where the information contained in the assessment came from. It is also recommended that the rationale for the decision as to where to place the resident in the home be recorded. It is recommended that the home check with residents that their choices and preferences in respect of daily living are being taken into account in current routines e.g. getting up and going to bed. • It is recommended that the home consult with residents about what food they would like to see included on menus. • It is also recommended that there is always fresh fruit and fruit juice on each unit. • It is further recommended that the home ensure that they are offering all residents at least 5 portions of fruit and vegetables a day. It is recommended that the written recruitment policy and procedure be updated to reflect the actual practice that should be followed in the home. It is recommended that all staff working on Nightingale have training relevant to their work in respect of mental health and dementia. Polices and procedures should be reviewed annually and revised where appropriate. It is recommended that more detailed records are made of supervision sessions with staff covering aspects of practice, philosophy of care and career development needs. 2. OP14 3. OP15 4. 5. 6. 7. OP29 OP30 OP33 OP36 DS0000020510.V279881.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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