CARE HOMES FOR OLDER PEOPLE
Dove`s Nest Nursing Home 17/19 Windsor Road Clayton Bridge Manchester M40 1QQ Lead Inspector
Geraldine Blow Unannounced Inspection 21st 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 Dove`s Nest Nursing Home DS0000021641.V251299.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. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Dove`s Nest Nursing Home Address 17/19 Windsor Road Clayton Bridge Manchester M40 1QQ 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) 0161 681 7410 0161 681 7410 Dove`s Nest Limited Ms Jane Rawsthorne Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability (1) of places Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One named service user is currently accommodated and receiving nursing care by reason of physical disability. Should this service user no longer require the accommodation offered by Dove`s Nest the service user category will revert to OP (old age). Nursing or personal care may be provided for a maximum of 31 service users of either sex aged 60 years or over. At any one time one younger adult aged 18 - 60 years can in addition be accommodated for nursing care / personal care, by reason of physical disability for respite care for a period of no longer than 3 weeks. Registration is subject to compliance with the minimum nursing staffing levels indicated in the Notice previously served in accordance with Section 13 of the Care Standards Act 2000 and dated 11th March 2005. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing for the service users assessed as requiring personal care only must comply at all times with the minimum levels set out in the Residential Forum guidelines ` Care Staffing in Care Homes for Older People`. 8th February 2005 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Dove’s Nest is a nursing home providing 24-hour accommodation for up to 31 older persons. The home is owned by Doves Nest Limited. The Responsible Individual, is Ms Helen Claffey The home is situated in the North of the City of Manchester. Local facilities and bus routes are within easy walking distance. Parking to the side of the property is available. The building is an extended and converted detached house set in its own grounds. Accommodation is provided on two floors, served by a passenger lift and the home is accessible to wheelchair users. Bedroom accommodation is on the ground and first floor. The third floor
Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 5 provides office space. There are 21 single and 5 double rooms. All rooms, with the exception of one single room, are provided with a wash hand basin. There are no en-suite facilities available. The double rooms have strategies in place for the maintenance of privacy. There are 3 lounges, a hair dressing room and conservatory/dining room, which is designated as a smoking area. The conservatory has patio doors leading out on to a small patio area, overlooking a wooded garden area, which enables service users to sit outside in warm weather. The house situated within the grounds of the home is currently being converted into an administration and training centre. The work is nearing completion and part of the building is in use. Dove`s Nest Nursing Home DS0000021641.V251299.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 the course of 7 hours on Wednesday 21st September 2005. During the course of the inspection, time was spent talking to the responsible individual, the registered manager, residents, a visitor and staff to find out their views of the home. Time was spent examining records, documents, residents and staff files. A tour of the building was also conducted. At the time of inspection the patio area was out of use due to refurbishment work being carried out in one of the lounges. Since the last inspection, in February 2005, the CSCI has not received any complaints. The home kept a record of any complaints made directly to them, which included details of the investigation and any action taken. During this inspection only a selection of the key National Minimum Standards were assessed. Therefore in order to gain a full picture of how the home meets the needs of residents, this report should be read with the previous and any future reports. What the service does well:
The home carries out assessments of each perspective resident before admission to the home to ensure that the home can meet all the needs of the resident. After the assessment the home writes to the resident or their relative informing them of the outcome. Where the need arises the home provides equipment for the prevention or treatment of pressure sores. If bedrails were used they had protective bumpers in place to help prevent injury. The manager said that the home had an open visiting policy. One relative spoken to confirmed this. He said that “the staff are very good and if you ask them to do something they will do it for you”. He also said that he visited his wife every day and “the staff always make me feel very welcome, I get cups of tea and I have my tea here every day with my wife”. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 7 One resident spoken to said “if you want help you do get it but I don’t ask because I can do it for myself”. Another resident said, “ I have a nice room and the staff look after me”. The home appeared to treat the residents with respect and dignity. The manager said that residents get choice with regard to their daily lives. Unless it is detrimental to their care, the residents can go to bed and get up when they choose. The staff spoken to confirmed this. Staff were seen to have a good relationship with the residents and were seen to be kind and patient when dealing with residents individual needs. The menu offers a choice of food at each mealtime. One resident spoken to said, “the food has improved a lot since the last chef left and you do get plenty of it”. The relative spoken to said, “the food is well presented and there is always enough of it”. Staff spoken to said that drinks and snacks were available on request to all residents. The home had a large supply of food that included lots of fresh fruit and vegetables. The home employs the services of a private physiotherapist. She attends the home on a weekly basis and holds a group physio sessions as well as individual physio session with residents. Also a beautician comes into the home every Tuesday and carries out treatments such as manicures. What has improved since the last inspection? What they could do better:
As identified at the last inspection some areas of the home required upgrading and redecorating. The responsible person stated that a decorating programme was in place to remove the dark wallpaper along the main corridor and to replace some of the bedroom furniture. Also plans were in place to extend the premises and increase the occupancy capacity and as part of the extension further re-furburbishment of the existing building would be undertaken. The plans also include an area, which would provide a telephone for residents to use in private because the home does not currently provide this. However residents can have a mobile phone or a private telephone in their room on request. The residents are then responsible for paying the bill.
Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 8 The home provided limited activities for residents and did not have a designated person responsible for organising activities. It is recommended that an activity co-ordinator is employed by the home and that the home documents that residents are regularly consulted about activities. Each resident had a plan of care detailing the actions to be taken by care staff to ensure all their needs are met, however they must contain detailed risk assessments to help avoid any accidents or risks to residents. The home must make sure that all medication is signed for so that a full audit trail is available. The home had a complaint procedure that had been given to all residents. However this needed updating and then all residents must be given a new copy. The home was in the process of reviewing the policy relating to the Protection of Vulnerable Adults. This must be completed as soon as possible and made available to all staff. The home obtains verbal references in addition to applying for a written reference. However, new staff must not be allowed to start work at the home until the 2 written references have been received. 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. Dove`s Nest Nursing Home DS0000021641.V251299.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 Dove`s Nest Nursing Home DS0000021641.V251299.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 The home undertakes an assessment of prospective residents care needs prior to their admission. EVIDENCE: Prospective residents have a pre-admission assessment to ensure that the home could meet all of their assessed needs. The assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. The manager said that following the pre-admission assessment the home confirms in writing to the prospective resident that the home is able/not able to meet their assessed needs. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Overall the health and personal care needs of the residents appeared to be met at the home. However, the plans of care must include detailed risk assessments. The system for recording all prescribed medicines needed some improvement to provide an accurate audit trail of medication. EVIDENCE: A sample of care plans were examined. In the main the plans of care were detailed and they had been reviewed on a monthly basis. However, in one file examined it clearly identified that the resident was peg fed but the only feeding regime was one for bolus feeding. The manager said that was the regime for her on admission. In 2 other files it was found that both residents had bed rails in situ yet a risk assessment had not been completed. In other files the risk assessment box had not been competed or the information was vague and did not constitute a risk assessment. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 12 The home had purchased a number of ‘Kirton’ chairs. These chairs would enable residents normally nursed in bed to be able to sit in the lounge. The use of the chairs must be risk assessed prior to their use. There was a daily journal completed for each resident but this contained vague statements for example “no change in condition” and it did not accurately reflect the nursing care given over a 24-hour period. Of the files inspected here was no evidence that the plans of care had been drawn up with the involvement of the service user and/or their representative. All residents were registered with local General Practitioners and had access to visiting healthcare professionals e.g., Dietician, Chiropody, Dentistry and Ophthalmology. On examination of the Medicine Administration Record (MAR) sheets it was noted that some prescribed medication e.g. creams, ensure drinks and dressings had not been signed for. All prescribed medication must be signed for by the person administrating them to facilitate audits and to ensure that the records are clear and accurate. The medication file contained some residents’ photographs, which acted as an aid to identification at the time of medication administration. It is recommended that a photograph of all residents is included in the file. In addition the file contained a list of current staff signatures. Inline with new legislation, from the 1st Aril 2005, the home had recently employed the services of an independent company to dispose of pharmaceutical waste. The home does not see the prescriptions before they are dispensed, nor do they have a copy of the prescriptions to use as an up to date copy of each service users medication. Professional guidelines indicate that the home should see the prescriptions prior to dispensing and good practice indicates a copy of the prescription should be kept of these prescriptions. From observations made during the inspection and discussions with members of staff and residents it appeared that the nurses and care staff treated the residents with respect and dignity. Privacy screens were available in the double rooms. The manager said that the preferred term of address would be documented on the front admission sheet. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 13 Dove`s Nest Nursing Home DS0000021641.V251299.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): 12, 13, 14 & 15 Meals appeared nutritious and a choice was available. However, limited activities are available to residents. EVIDENCE: The manager said that residents special birthdays/anniversaries were celebrated usually by a party were family/friends were invited to share in the celebration and the manager said that as part of the pre admission process the residents are asked about their hobbies and interests and it is included in the care planning process. However there was no evidence that the residents had been consulted in developing individual activities or a programme of activities. There was no designated staff member employed to co-ordinate activities. The home operated an open visiting policy and visitors could be received in private or in any of the communal areas. The staff and relative spoken to confirmed this. Visiting was only restricted if requested by a resident or their advocate. Any restriction was formally recorded and communicated to all persons concerned. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 15 From observations of the inspectors and residents spoken to it appeared that residents were able to exercise choice and control with regard to their day-today lives. Several of the bedrooms had been personalised with residents belongings brought in from home. The menu inspected had been developed on a 3-week rota system. The home was in the process of interviewing for a new chef. The meals offered appeared nutritious and wholesome. The home did not have a menu on display although the manger and the chef told the inspector that residents are consulted each morning with the choices of the day. Dove`s Nest Nursing Home DS0000021641.V251299.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 & 18 The home had a complaints procedure that had been given to residents, however it required updating. The home’s policies and procedures required reviewing in order to protect the residents’ health. EVIDENCE: The home had a complaint procedure and every resident had been given a copy. This was seen to include the correct name and address of the registering body, Commission for Social Care Inspection (CSCI), but it also made reference to the old registering body The National Care Standards Commission (NSCS) and it did not include a 28-day time frame. A record was held of all complaints including investigations and actions taken. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 17 The home had policies and procedures relating to abuse/protection of vulnerable adults and Whistle Blowing. The home had a copy of the Department of Health “No Secrets” Guidance and a copy of the Manchester Multi-Agency Policy for the Protection of Vulnerable Adults from Abuse. The Responsible Individual, in conjunction with the staff, was in the process of developing a policy that takes into account the Department of Health “No Secrets” Guidance. The policy must ensure that it clearly demonstrates the procedure to be taken in informing the relevant local authority of adult protection issues. This requirement is outstanding from the previous inspection and must be met as a matter of some urgency. Staff spoken to confirmed that they had received training in the actions to be taken in the event of an allegation of abuse. In all but one instance the appropriate responses were given. This was discussed with the responsible individual during the inspection. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 18 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, 24 & 26 The homes environment was generally clean, however the majority of the home was showing signs of “wear and tear”. EVIDENCE: The location and layout of the home was suitable for its stated purpose. As already identified in this report some areas of the home are in need of refurbishment and redecoration due to age and general wear and tear. Due to the proposed extension and planned refurbishment to the existing areas of the home no requirements have been made in this report. The requirements from the last inspection that locks must be provided on resident bedrooms suited to their capabilities and accessible to staff in emergencies and that a lockable storage space must be provided had not been met. The responsible individual stated this had not been addressed due to the
Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 19 proposed major refurbishment. The requirements have been reiterated in this report, as they must be included in the proposed plans. In addition the requirement from the last inspection that the freestanding wardrobes in residents private accommodation must be secured to the walls in an effort to reduce the possibility of avoidable accidents had not been met. Laundry facilities are sited away from the food preparation area. The home had policies relating to infection control and had received the guidelines from the infection control nurse. Some recommendations inline with this guidance have been made it this report. It was noted that the bathrooms and toilets did not have a supply of Personal Protective Equipment (PPE) i.e. gloves, aprons and wipes as recommended by the infection control nurse. Only a limited number of bedrooms had a supply of PPE although the manager said that the majority of residents required personal care in their bedrooms. The home had 2 slings to be used with the hoists and the manager said that a large number of residents required the use of the hoist. To prevent the risk of cross infection it is recommended that an individual sling should be provided for each resident requiring the use of the hoist. The hoist was not being cleaned in-between resident use however it was observed to be generally clean. The responsible individual said that the home did have a supply of alcohol gel for staff to use. It is recommended that these be wall mounted as discussed during the inspection or individual gel being purchased for staff. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 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): The numbers and skill mix of staff appeared to be sufficient to meet the needs of the residents. The homes recruitment policies and procedures appeared to promote the safety and wellbeing of the residents. However, some short falls were identified. EVIDENCE: At the time of the inspection the home accommodated 28 residents i.e. 25 residents assessed as requiring nursing care and 3 residents assessed as requiring personal care only. On examination of the staff rota it was identified that one day in the week did not have the required number of trained staff. However the shortfall was filled before the end of the inspection. The numbers and skill mix of the staff, then appeared to be sufficient to meet the needs of the number of residents accommodated. The sample of staff files inspected did not contain all the information and documents listed in Schedule 2 of the Care Home Regulations 2001. The files inspected did not contain a photograph and 2 of the files did not contain a written reference. Both files contained 2 verbal references and one written reference. Evidence was seen that the responsible individual had made every effort to obtain the 2nd written reference without success. The responsible
Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 21 individual was reminded that staff must not take up post until 2 satisfactory written references have been obtained. There was a computerised system in place to check expiry dates of PIN numbers and work permits. Evidenced was seen that CRB and POVA checks had been undertaken on all newly appointed members of staff. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 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): EVIDENCE: None of the Standards in this section were assessed on this occasion. Dove`s Nest Nursing Home DS0000021641.V251299.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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x x Dove`s Nest Nursing Home DS0000021641.V251299.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 13,15,17 Schedule 3 Requirement 1. The plan of care must include detailed risk assessments with particular attention to the use of restraints i.e bed rails and Kirton chairs. 2. An accurate record must be kept of the nursing care provided including a record of the residents condition and any treatment given. 3. The plan of care, where possible, must be drawn up with the involvement of the resident in a style accessible to the resident. Once agreed it must be signed for by the resident whenever possible and/or their representative. 2. OP8 14 & 17 Schedule 3 13 The individual plan of care must accuratley reflect the residents nurtitional needs i.e an accurate peg feeding regime. 1. All prescribed medication must be signed for by the person administrating them. (Previous timescale of 1/4/05 had not been met)
DS0000021641.V251299.R01.S.doc Timescale for action 01/11/05 01/11/05 3. OP9 01/11/05 Dove`s Nest Nursing Home Version 5.0 Page 25 2. Prescriptions must be seen and checked prior to sending them to the pharmacy. 2. An up to date record of service users medication must be maintained by the home 4. OP10 16 Within the proposed refurbishment the home must provide telephone facilities, which are suitable for the needs of service users and make arrangements to enable service users to use such facilities in private. (Previous timescale of 30/4/05 had not been met) Evidence must be provided that residents are consulted regarding the planning of activities, outings and entertainment. (Previous timescale of 30/4/05 had not been met) 1. Reference to NCSC must be removed from the complaint procedrue. 2. A 28 day time frame must be added. 3. On completion of the above all residnets must be issued with the updated procedure The homes policies and 01/11/05 procedures relating to the Protection of Vulnerable Adults must take into account the Department of Health “No Secrets” Guidance. (Previous timescale of 30/4/05 had not been met) 8. OP24 23 Within the proposed
DS0000021641.V251299.R01.S.doc 30/04/06 5. OP12 16 01/11/05 6. OP16 22 01/11/05 7. OP18 12 30/04/05 Dove`s Nest Nursing Home Version 5.0 Page 26 refurbishment the responsible individual must ensure that: 1. Locks are provided on residents’ bedrooms to respect privacy and dignity. The locks must be suited to their capabilities and accessible to staff in emergencies. The provision of keys must be the result of the risk management process. 2. All residents are provided with a lockable storage space. (Previous timescale of 30/4/05 had not been met) The responsible individual must ensure that the freestanding wardrobes present within the service user’s private accommodation are secured to the walls in an effort to reduce the possibility of avoidable accidents. (Previous timescale of 30/4/05 had not been met) 1.Staff files must contain an up to date photograph 2. Two written references must be obtained before appointing a member of staff. 9. OP24 13 30/11/05 10. OP29 19 Schedule 2 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 27 1 2. 3. OP9 OP12 OP26 It is recommended that the drug administration file contain an up to date photograph of all residents to aid easy identification. It is recommended that the home employ the services of an activity organiser. It is recommended that: 1. Personal Protective Equipment (PPE), which includes gloves, aprons and wipes should be made available in residents’ bedrooms, toilets and bathrooms to facilitate the management of personal care. 2. The home should ensure equipment such as the hoist is cleaned in between each use either by the use of equipment wipes or soap and water. 3. To prevent the risk of cross infection an individual sling should be provided for each resident requiring the use of the hoist. 4. The home should consider purchasing individual hand held alcohol gel for staff or wall mounting alcohol gel. 5. The home should develop and implement a policy to include the above. Dove`s Nest Nursing Home DS0000021641.V251299.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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