CARE HOMES FOR OLDER PEOPLE
De Lacy House De Lacy House 42 De Lacy Way Winterton North Lincolnshire DN15 9JX Lead Inspector
Beverley Hill Unannounced Inspection 09:30 26 October 2005
th 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 De Lacy House DS0000033109.V262470.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. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service De Lacy House Address De Lacy House 42 De Lacy Way Winterton North Lincolnshire DN15 9JX 01724 733755 01724 735491 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) North Lincolnshire Council Carol Mobbs Care Home 30 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (24), of places Physical disability (6) De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. That the Intermediate Care Services provided to promote short-term intensive rehabilitation are sited in a designated area. That the mixed age range of 18-65 years and over 65 years applies only to the six places registered for Intermediate Care Services. That care staff receive appropriate training in relation to techniques for rehabilitation. Service users occupying the new bedrooms and accessing bathing facilitiies in the main unit do so on a temporary basis until the new bathroom is completed in July 2005 within the Porier Suite. 22nd March 2005 Date of last inspection Brief Description of the Service: De Lacey House is owned by the local authority and situated in Winterton. Part of the building includes the Poirier Suite, a designated unit providing intermediate care services offering short-term rehabilitation to a mixed age range of people 18-65years and over 65 years. The unit is managed as part of De Lacey House and staff members provide personal care. Clinical support for the service is via the Primary Care Trust Intermediate Care Service Team consisting of a GP, qualified nurses, occupational therapists and physiotherapists. It has six single bedrooms, two of which have en-suite shower rooms and two en-suite bathrooms. Two of the rooms have ceiling tracking hoists into the bathrooms and equipment to aid people with disabilities. The suite has a kitchen, sitting room and a dining room. The main part of De Lacy House has twenty-four beds and delivers personal care to older people, four of whom may have needs associated with dementia. The home also offers a day care service for up to six people. De Lacey House is a purpose built unit with four lounges and a large dining room. One of the lounges has a ‘Loop System’ installed to aid those service users who have a hearing impairment and one of them is designated for activities used by day care services. All the bedrooms are single and personalised to varying degrees. The home has ten single toilets strategically placed, two bathrooms and one shower room. Both bathrooms have been fitted with Parker Baths to aid
De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 5 access. A further bathroom is situated in the section designated for day care services. The home surrounds a courtyard patio area that has shrubs and plants and a covered area at one end. A further patio area is outside the separate entrance to the Poirier Suite. The home has ramps to all entrances. There are gardens to the front, side and rear of the building and adequate car parking facilities. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The Local Authority was completing a management review of Delacy House and two senior managers had replaced the registered manager during this time. The Inspector spoke to both managers, two catering staff and a senior care officer who was on duty at the time of the inspection. Throughout the day the Inspector spoke to several people who lived in Delacy House and attended for respite care. The inspector looked at a range of paperwork in relation to staff rotas, meetings, care plans, accidents, risk assessments, medication records, and policies and procedures. The Inspector also checked that people who lived in the home had the opportunity to suggest changes and were listened to. The Inspector completed a tour of the building and observed care practices in the dining room. What the service does well: What has improved since the last inspection?
De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 7 The home had done some of the things the Inspector had asked them to do at the last inspection but not all. There had been a big improvement in the communal areas of the home. The entrance, corridors and dining room had been redecorated and carpeted and new lighting installed. People spoken to had noticed the difference and were pleased with the results. Care staff that work in the intermediate care service had received training from the nurses, occupational therapists and physiotherapists. A form had been devised for staff or the person themselves to complete when exercises were part of their recovery plan. The home had forwarded the certificate that evidenced stored water had been checked for legionella. The home had obtained an up-to-date British National Formulary as a medication reference for staff. What they could do better:
The care that people required was written down in care plans. The care plans for people in the intermediate care services were more comprehensive than those for people in the main unit, which were currently being checked by staff. The care plans did not always reflect all the care that people needed and what staff needed to do to help people. When changes occurred in peoples care needs and when professionals gave instructions, the staff did not always write it down in the care plan. For example one person was to have regular ice packs to their knee to reduce swelling but this was not on the care plan. Three weeks after admission one person was assessed as having a risk of developing reddened pressure areas but a plan of care was not produced to prevent this although a pressure cushion was provided. Although an exercise form had been devised this was not always filled in. For example one person was to have exercises to strengthen their legs and mobilise their knee but the exercise sheet was not completed and the inspector did not know if instructions had been carried out. The home did not always ensure they receive assessments for the people funded by care management. These were really important because all staff needed to have information about the people living at the home and when changes occurred in their needs so they could support them fully. They did receive care plans from care management. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 8 Risk assessments could be updated more often when people’s needs changed and in some instances they needed completing when risks had been identified. In one case a GP’s direct instructions were not carried out and a person staying at the home was not able to have a particular treatment. The management of medication requires attention to make sure that all medication is signed into the home and that staff administer it in line with policies and procedures. Most care staff were receiving at least six supervision sessions a year but not all. Supervision was important to make sure that staff were aware of their role and tasks, were completing their jobs properly and could discuss any issues with their line manager. Senior managers need to make sure that the review of management arrangements are completed quickly. 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. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 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 De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 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): 3, 4 and 6 Service users cannot be assured that their needs can be met by the home, as the home did not consistently obtain assessments completed by care management, prior to admission, which could mean that vital information is missed and the required care not provided. The home provided an effective intermediate care service. Deficiencies in care plans affected the homes ability to meet all the needs of current service users in the main unit. EVIDENCE: The senior care officers completed in-house assessments and there was evidence that some assessments completed by Care Management were obtained by the home prior to admission but this was not consistently the case in all care files examined. The assessments were important as they provided vital information for the care planning stage. This was particularly important as the home admitted people for short stays in times of crisis at home and to give the main carer respite. The assessment was also crucial in deciding whether the home was able to meet the needs of the person requiring admission. Assessments for admission to the Intermediate Care Service were obtained
De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 11 from the multi-disciplinary team. In-house assessments and care plans were produced and care staff within the intermediate care unit worked closely with health professionals such as doctors, nurses, physiotherapists and occupational therapists. One of the assessments examined was comprehensive and detailed involvement and agreement of relatives. Progress for those people receiving intermediate care was monitored from admission through to discharge home and the care plans focussed on improving and maintaining people’s independence. People spoken to were very pleased with the service they received in the intermediate care unit. One person stated, ‘It’s like a hotel, the staff are very nice’. Deficiencies in care planning and risk assessments in the main unit affected the homes ability to meet all the service users needs effectively. The homes training plan included dementia care, bowel care, risk assessment, chronic diseases, challenging behaviour and stoma care as well as mandatory training. Care staff working on the intermediate care unit had received training in specific areas from members of the health care team. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 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 9 There had been very little change in the care plans for service users in the main unit although there was improvement noted in the care plans for people receiving intermediate care. Service users health care needs were not consistently monitored and a lack of risk assessments and poor management of medication placed them at risk. EVIDENCE: There had been an improvement in the care plans produced for people occupying intermediate care beds. These focussed more on rehabilitation and supporting people to regain their independence. They had clear tasks for staff and monitored progress from admission through to discharge home. Staff had started the process of updating care plans in the main unit to bring them into line with those for intermediate care. Five care plans were examined in detail and it was clear that improvements were required. For example, care plans did not contain all assessed needs, were not updated as needs changed, did not have clear tasks for staff and were not evaluated effectively, otherwise these issues would have been identified and addressed.
De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 13 Risk assessments for moving and handling people had sections missing from them. Managers were able to show the inspector completed moving and handling risk assessment documentation but could not account for why only half of the form had been used in several assessments. The full form was important as it detailed clear tasks staff needed to perform to minimise risks when moving and handling people. Some risk assessments needed updating as people’s needs change, for example, a nutritional risk assessment for one person was completed in 2003 but had not been updated. Some service users had risks identified for example, falls, smoking and pressure areas, but risk assessments had not been completed at all. There were some health related issues that required attention. Some health care monitoring forms were not consistently completed even though issues had been identified that required close monitoring, for example a weight chart and a bowel chart for one person and a skin integrity chart for another. A GP had left instructions regarding one service user but these had not been carried out and the person was unable to have a particular treatment. One person spent all their time seated in a wheelchair and required assessment for more appropriate seating. The managers were aware of this situation and were to request a reassessment from the occupational therapist. Daily records did not give a full picture of the care provided and did not consistently follow on to the next shift. This was important as care issues could be missed and not passed onto staff. One person who attended for day care had no entries of any activities completed other than they ate their lunch and quality time records consisted of entries of ‘chats’ conducted during escorts to and from the home. The service users care plan was very basic and did not contain all their assessed needs. Management of medication required attention. Medication was left in front of a service user and not witnessed as taken by staff, medication for service users on respite was not signed into the home, one persons Temazepam medication was not signed in or stored correctly, the home still had medication for one person who had been discharged home and a particular form of eye drops was not stored as per manufacturers instructions. Staff must adhere to policies and procedures when administering medication and all medication must be signed into the home and stored appropriately. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 14 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): 13 and 15 The home provided an environment that encouraged contact with family, friends and the local community. There was choice available at mealtimes and planned extensions to the menu will further enhance the variety on offer for service users. Not all staff were aware of the nutritional needs of service users. EVIDENCE: Service users spoken to confirmed that their visitors were made to feel welcome and could visit at any time. The Inspector saw open visiting and people were offered refreshments. The home had links with local schools and churches. The home supported activities that were available to the service users, the local community and specific groups. For example, a volunteer ran a friendship club in the dining room one day a week and bingo was held weekly for the local community and residents of De Lacy House. One of the small lounges was used by a travelling day service once a week for the local community and some service users from the home. A craft club was held on Mondays and on Thursdays there was Adult Education sessions for service users, staff and
De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 15 people from a local sheltered housing scheme. The library delivered books on a regular basis. Three service users from De Lacy House visited a day centre on Tuesdays for ‘balance’ sessions as part of the homes involvement in falls prevention. Service users spoken to were happy with the provision of meals. They had recently made suggestions for changes to the menus. The menus were in the process of being updated to offer a wider variety and choice to people. Menus were on display and offered choices at each meal. Carer practice was observed during lunch and it was noted that one staff member did not sit and provide the support required to one service user but intermittently returned to give support whilst standing up. This made the support provided appear disjointed and they were not available to offer full support such as the wiping of food spillages as they occurred. This appeared to be a one-off incident as there were other examples of good practice observed of staff assisting people to eat in a sensitive way. There was plenty of staff available to assist service users. Whilst offering choices of desserts two staff members asked service users if they were diabetic. All staff should be aware of service users nutritional needs and not have to ask them at each meal. The meal was observed as a social occasion, people were chatting to each other and staff, and some obviously enjoyed the background music. During the observation the managers reminded staff not to limit the choice of tea only when offering service users a drink after lunch. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 16 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 Service users felt able to make complaints and the complaints procedure was clearly displayed in the home. However the homes inability to produce the complaints records for inspection meant that the standard could not be fully inspected. EVIDENCE: The homes complaint procedure was clear and displayed in the entrance. It had appropriate timescales for resolution and included contact details of other agencies. Service users spoken to stated they would complain if they needed to but rarely did. The managers were unable to locate the complaints folder so this standard could not be assessed fully. The annual return completed by the home stated that they had not had any formal complaints since the last inspection but a few niggles had been received and addressed. However a report completed after a monthly visit by the Responsible Individual indicated that one complaint had been received and investigated. Staff members were aware of the documentation process regarding complaints and tried to sort out minor issues before they became formal complaints. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home provided a homely, clean and comfortable environment for service users. EVIDENCE: De Lacy House provided ground floor accommodation and was built around a central courtyard. The main unit had four lounges, one of which has a ‘Loop System’ installed to aid those service users who have a hearing impairment, a large dining room, ten single toilets, two bathrooms and one shower room. All the bedrooms are single and personalised to varying degrees. The Poirier Suite had six bedrooms, four of them en-suite, a lounge, a dining room and a rehabilitation kitchen. A new bathroom for the two service users in the new bedrooms was planned for completion in November. The home was suitable for its intended purpose. There had been improvements in the environment since the last inspection. The entrance, corridors and dining room had been redecorated and carpeted and new lighting installed. People spoken to had noticed the difference and were pleased with the results.
De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 18 The home looked welcoming and comfortable. It was noted to be clean and tidy and free from any offensive odours. People spoken to were happy with the cleanliness of their rooms and the home in general. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 The home provided sufficient numbers of staff on each shift to meet the care needs of service users. Although some progress was made with mandatory training, not all staff had up to date certificates, which means that service users could be put at risk of inadequate care. EVIDENCE: Staff rotas were examined and showed that during the day and evening there was four care staff members in the main unit and two in the Poirier Suite with a senior care officer covering both areas. There were three care staff members at night and a senior care officer sleeping in for the whole building. The extra person on nights was a new addition as staff members had expressed concerns to management that two waking night care workers was insufficient. A general assistant supported with drinks, meals and escorts for day care service users and was employed for morning and afternoon/evening shifts. The home employed a range of catering and domestic staff. The rota’s stated who was on duty and in what capacity. Service users spoken to were complimentary about the staff team. Staff received an induction that was competency based and signed off by senior staff on completion. Budgeting included provision of at least three days
De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 20 paid training a year. It was noted that although the home had access to a corporate training plan, not all staff had completed mandatory training or updates, which could result in inadequate care provided to service users. Not all staff had completed protection of vulnerable adults from abuse training. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36 and 38 Service users are placed at risk by failures to assess and minimise identified risks and by poor management of medication (see health and social care). Consistency of approach to care is affected by temporary management arrangements. EVIDENCE: The CSCI has been notified that the registered manager has been suspended pending an investigation into their management of the home. Interim management arrangements have been put in place. The CSCI will await the results of the investigation. Supervision records were examined and although they showed that some care staff received six supervision sessions per year not all had done so. Individual supervision records and logs were maintained by senior care officers and evidenced that key worker issues and training requirements were discussed,
De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 22 files were examined and advice given and recorded. Staff also received annual appraisals. Policies and procedures were kept up-to-date, accidents were recorded and reports sent to relevant agencies. The homes annual return stated that equipment had been serviced and fire safety checks completed. Repairs were maintained and new kitchen equipment had recently been purchased. Individual risk assessments had not been completed consistently for particular people, which meant that measures were not put in place to minimise the risks. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X 2 X 2 De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 24 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 OP7 Regulation 15 Requirement The registered person must ensure that all assessed needs and instructions from professionals are included in care plans (previous timescale of 30/06/05 not met) The registered person must ensure that daily records are comprehensive and follow through to the next shift any important information that has been highlighted (previous timescale of 22/03/05 not met) The registered person must ensure that all care plans detail tasks required by staff to meet needs (previous timescale of 30/06/05 not met) The registered person must ensure that the full manufacturers instructions are written when staff transcribe medication onto the medication record (previous timescale of 22/03/05 not met) The registered person must ensure that the home consistently receives
DS0000033109.V262470.R01.S.doc Timescale for action 31/12/05 2 OP7 12(1)(a) 31/12/05 3 OP7 15 28/02/06 4 OP9 13(2) 26/10/05 5 OP3 14 26/10/05 De Lacy House Version 5.0 Page 25 6 OP7 15 7 OP8 13(1)(b) 8 OP8 13(4) 9 OP9 13(2) 10 OP15 12(1)(a) 11 OP16 12(1)(a) 12 OP31 9 13 OP36 18(2) 14 OP38 13(4) assessments completed by care management prior to admission. The registered person must ensure that care plans are updated as needs change and are evaluated effectively. The registered person must ensure that GP instructions are followed and monitoring charts completed consistently. The registered person must ensure that all activities that pose a risk are assessed and steps are taken to minimise any risks. The registered person must ensure that the management of medication is in line with pharmacy regulations and inhouse policies and procedures. The registered person must ensure that all staff members are aware of service users dietary needs and they are supported during meals in a sensitive way, ensuring dignity. The registered person must ensure that the complaints folder is located and audited to establish any patterns. The registered person must ensure that the CSCI are informed of the outcome of the management review. The registered person must ensure that all care staff receive a minimum of six formal supervision sessions per year. The registered person must ensure that all staff are aware of the risk assessments completed for service users deemed to be at risk of particular activities and that these are reviewed. 31/12/05 26/10/05 31/12/05 27/10/05 26/10/05 31/12/05 31/12/05 28/02/06 31/12/05 De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 26 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 OP31 Good Practice Recommendations Senior managers should complete the management review quickly to enable the home to regain stability. De Lacy House DS0000033109.V262470.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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