Inspection on 30/06/06 for Dussindale Park Nursing & Residential Home

This inspection was carried out on 30th June 2006.

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

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

Other inspections for this house

Dussindale Park Nursing &... 11/11/08

Dussindale Park Nursing &... 26/06/07

Dussindale Park Nursing &... 07/11/05

Dussindale Park Nursing &... 05/05/05

Dussindale Park Nursing &... 26/10/04

Dussindale Park Nursing &... 29/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Dussindale Park Nursing & Residential Home Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD Lead Inspector Maggie Prettyman Unannounced Inspection 30th June 2006 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 Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dussindale Park Nursing & Residential Home Address Mary Chapman Close Dussindale Norwich Norfolk NR7 0UD 01603 701900 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) Alphacare Services (UK) Ltd Mrs Johanna Paul Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Fifty-eight (58) Service Users may be accommodated of either sex who are aged over 65 years. From time-to-time 2 service users between the age of 50 and 65 years may be accommodated. The total number not to exceed fifty-eight (58). Date of last inspection 7th November 2005 Brief Description of the Service: Purpose built in 1994, Dussindale Park is situated in a modern residential suburb of Thorpe St Andrew on the outskirts of Norwich. The home can accommodate 58 older people with residential or nursing needs, in 38 single and 10 double rooms; 38 of the rooms have en-suite facilities and some of the ground floor rooms open up to patio areas. The accommodation is on the ground and first floor levels, and can be accessed by passenger lift. The second floor is used for offices and storage. The surrounding lawns and garden areas are well maintained and can be accessed by service users. There is ample parking space at the front and to the rear of the premises. The home is supported by the local GP practices and other health professionals. The Range of fees charged is £325 - £600. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced visit to the home with a full tour of the premises, discussion with 16 service users, two relatives, two care workers and the manager. Prior to the inspection, records relating to the home since the last inspection as well as written feedback from 11 service users, 8 relatives, 3 GPs and 1 health care professional were used to plan specific areas to look at. The home was found to have good standards relating to information given and assessments made prior to service users admission. Good standards were also found for quality and maintenance of the environment and management and administration of the home. Health and personal care standards were found to be adequate, as were those relating to daily life and social activities and complaints and protection. There have been recent issues relating to staffing and care practice, which are being addressed. The inspector found a warm and pleasant atmosphere in the home, and noted that staff on duty were hard working, professional and courteous. What the service does well: What has improved since the last inspection? The service user guide has been improved. Care plans are being updated, and written accountability records are now being kept. Pressure mats are being used to alert staff to service users at risk of falling. The number of staff has been increased on some shifts. The manager has encouraged discussion of palliative care with service users and their relatives. A memory corner has been created to encourage recall and reminiscence, and two budgies now reside in the home. Standards of cleaning have improved greatly. Progress is being made in terms of improving numbers of qualified staff. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 6 What they could do better: A number of requirements and recommendations have been made at the end of this report. The requirements include: • • • • • • • • • • • • • The updated Service User guide should be given to all existing service users. Repeated Requirement The needs assessment undertaken prior to admission should include consideration of compatibility of service users with the existing group. Care plans must be updated into one style of record. Improvement in care notes needs to be continued. The home needs to actively monitor care practice to ensure that there is no recurrence of recent poor practice. An effective system of identifying service user clothes must be in place All staff handling food must be appropriately trained. Repeated Requirement The Commission must be immediately notified of serious events relating to the health, safety and welfare of service users. Bathroom areas must not be used for storage of inappropriate items Current positive steps to improve staff communication, harmony and training must be maintained. Staff must not commence work prior to the receipt of CRB checks The home must continue to work toward its NVQ targets. Repeated Requirement The positive support and encouragement of whistle blowing must be maintained by the organisation. The recommendations include: • • • • • • • • • • Care notes should be kept in care records only Regularity of access to bathing should be monitored Staff should check pain relief requirements regularly More intellectually stimulating activities and 1:1 sessions should be available. Photographs of the management team should be on display A wider variety of fresh foods, food types and dishes should be available. The home should monitor minor complaints, comments, suggestions and compliments The amount of linen inappropriately sorted should be monitored. Staff should be given dementia care training. Staffing levels should be reviewed to check that service users’ needs are being met. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 7 • • • • • The manager should continue to foster cultural understanding in the home. Staff should be given notice in order to prepare for supervision sessions. The manager should be offered professional supervision and support Results of satisfaction surveys should be given to service users and their relatives. A more detailed audit of accident records should take place. 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. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5, and 6 The overall quality outcome for these standards is good. Prospective service uses have the information they need to make an informed choice about where to live. The service user contract is currently under review. No service user moves into the home without having their needs assessed and been assured that their needs will be met. Prospective service users and their representatives have the opportunity to visit and assess the quality, facilities and suitability of the home. Service users on short stays are encouraged to maximise their independence. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 10 EVIDENCE: An improved service user guide has been written since the last inspection. One service user questioned said that the information provided in the guide was accurate and had prepared him well for his admission. The manager plans to give a copy of the updated guide to all existing service users. It is recommended that all service users be given an up to date service users guide. The business is in the process of writing a more appropriate contract for service users. Evidence of basic but comprehensive needs assessment compiled prior to admission was seen in service user files. Evidence was seen of a service user whose needs were causing distress to another service user. It is required that the assessment of need also considers the compatibility of service users to the group that they will be joining. Service user feedback forms shows that relatives normally visit the home prior to a service users admission. Discussion with service users demonstrated that health issues frequently prevent them visiting themselves. Discussion with the manager and care staff show that a good understanding of the importance of the maximising of independence for short stay service users is in place. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 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 and 11 The overall quality outcome for these standards is adequate. 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 are protected by the homes policies and procedures for dealing with medicines. The home has recently had to deal with serious complaints about the treatment of service users by a minority group of staff that have subsequently been dismissed. Service users feel that they are treated with respect and that 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. EVIDENCE: Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 12 Individual care plans were seen in service user files. A new style of plan is being implemented. It is required that the home bring all existing service user plans up to date in this format to aid consistency. A diary was found to contain records, which had not been updated in care notes. It is recommended that only care plan notes be kept to ensure that all relevant information is in one place. The care team have worked hard since the last inspection to improve the quality of notes kept. It is required that improvements continue to be made to the quality of care notes recorded. Examination of records and discussion with service users showed that sometimes people do no have access to regular baths due to staff shortage. It is recommended that the regularity of access to bathing be monitored to ensure that this occurs regularly. Detailed notes and plans of care were seen for service users with pressure areas regularly monitored. Vulnerable service users are given pressure mats to monitor and prevent falls. Feedback questionnaires from health professionals show that in general people’s health care needs are met by the home. Inspection of drugs and records shows that the home operates a safe system of medication. Evidence of regular audit of medicines and action taken to address minor areas of non-compliance was also seen. A comment on service user feedback forms indicates that staff may not always be recognising the need for pain relief. It is recommended that staff dispensing medication always check if pain relief is required. The home has recently had to address issues relating to alleged malpractice by staff who have been identified and who no longer work in the home. Despite this, service users and relative feedback forms and interviews with many service users on the day demonstrate that, service users feel that staff currently employed in the home are kind and hard working. It is required that the home continues to actively monitor care practice to ensure that there is no recurrence of recent issues. The manager has used recent relative and resident meetings to encourage people to discuss palliative care. Most people remain in their room in the home for their final days rather than going to hospital. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 13 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 The overall quality outcome for these standards is adequate. Service users do not always find that the lifestyle in the home satisfies all their social, cultural or recreational needs. Expectations, preferences and religious needs are met. Service users maintain contact with their family, friends and community if they wish. Service users are helped to exercise choice and control in their lives. Service users receive a balanced diet in pleasant dining areas, but the variety of food and food types can be limited. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 14 EVIDENCE: Comments from service users and their relatives show that whilst a programme of activities is in place, some people experience the activities to be limited and lacking in intellectual stimulation. Several people expressed the wish for 1:1 activities for more disabled service users. It is recommended that a wider variety of activities are made available which offer more intellectual stimulation, and that 1:1 activities take place when possible. Since the last inspection a “Memory Corner has been developed with items to aid recall and reminiscence. Discussion with service user relatives shows that visitors are welcomed and supported in the home. It is recommended that photographs of the management team and key staff be displayed to enable service users and visitors to identify the responsible person on duty. Almost without exception, service users rooms were seen to contain a variety of personal possessions. Service user satisfaction surveys are conducted and responded to. The home has identified problems with the labelling of service user clothes. All unmarked clothes are kept on a rail for relatives or service users to identify. Consultation with relatives has led to a new system being trialled. It is required that if this does not solve the problem, that an effective system of identification of peoples’ clothes is put in place. Dining areas in the home are pleasant and cheerful. The catering staff go round the home twice daily to ask service users for their choice of dish from the menu. The menu itself is at times repetitive and lacks variety in foods and types of dish. It is recommended that a wider variety of foods and dishes be regularly made available. The environmental health officer has recommended that kitchen staff attend the new food hygiene training course commencing in August. It is required that all staff that handle food must be trained in food hygiene. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 15 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 and 18 The overall quality outcome for these standards is adequate. Service users and their representatives are confident that their complaints will be listened to, taken seriously and acted upon. The home has taken action to protect service users from alleged misconduct by some identified care workers. EVIDENCE: Evidence in the complaints file and from relatives and service user feedback sheets demonstrates that complaints are taken seriously by the home, and that action is taken to resolve them. A number of cards, and comments made by service users and their representatives, demonstrate that many compliments are made about the service provided. It is recommended that the home records comments and suggestions, as well as compliments about the service to provide a wider range of information for audit. There have been two adult protection investigations in the home since the last inspection, the most recent as a result of whistle blowing by a staff member. Whilst this situation is far from satisfactory, there is evidence that the staff team feel confident in reporting issues to the manager, and that this has, in part, been brought about by increased awareness from training and team meetings. It is required that the current positive and supportive approach to whistle blowing is maintained by the organisation. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 16 Examination of records demonstrated that the commission is not always notified of serious events in the home. It is required that the commission is notified immediately when serious incidents occur in the home. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 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, 20, 21 and 26 The overall quality outcome for these standards is good. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Bathroom areas are used inappropriately for storage of equipment. The home is clean, pleasant and hygienic. EVIDENCE: A tour of the building and inspection of maintenance records demonstrated that the home is well maintained and meets service user needs in a homely and comfortable way. Communal lounges and the small garden were seen to be tidy and well furnished. The new memory corner and resident budgies have been an improvement since the last inspection. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 18 The previous recommendation that bathrooms be kept clear of clutter has not been met, this recommendation is repeated again. The tour of the building demonstrated that the home is clean, pleasant and hygienic, free from odours and has good infection control systems. The cleaning staff have changed recently, and feedback from service users and their relatives was positive in this respect. The laundry is clean and well organised. Linens are occasionally inappropriately sorted by care staff. It is recommended that the home monitors the amount of inappropriately sorted linens and rectify this problem. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 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, 28, 29 and 30 The overall quality outcome for these standards is poor. The numbers and skill mix of staff does not always meet service users’ needs. The home has not yet met its recommended targets for NVQ training. Service users are supported and protected by the homes’ recruitment policies, but CRB checks are not always in place prior to staff commencing work. Recent training programmes have improved staff competence and awareness. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 20 EVIDENCE: Feedback from service users and their representatives and information gained during the inspection demonstrate that the home has had a number of difficulties relating to numbers and skills of staff. The team has lacked cultural harmony, and issues relating to language and practical skills have been raised. These issues have, at times negatively affected service delivery. The manager has addressed these problems, and discussion with staff showed that the team is now more settled and recent training opportunities have led to increased awareness and improvements in practice. It is required that the current positive steps taken to improve communication, staff relationships and training are maintained. Positive information about different cultures has been included in the homes’ newsletter. It is recommended that further events and information given foster greater cultural understanding for both staff and service users. It is also recommended that the home continue to monitor staffing levels to ensure that service user needs are met. NVQ targets are not met. However 5 staff have signed up for modern apprentice training and external funding has been agreed for “Train to gain” training in August. It is required that the home continues to work toward NVQ training for unqualified staff. Examination of staff personal files demonstrates that a thorough process of recruitment and vetting takes place prior to appointment of staff. There is a shortfall in this process in that CRB checks are frequently not in place prior to staff commencing work. It is required that CRB clearance is gained on all staff prior to their being appointed. Evidence from staff files and discussion with staff on the day of inspection demonstrate that induction training takes place for all new staff. Evidence of mandatory training was also seen. It is recommended that staff be given appropriate Dementia Care training. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 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, 33, 35, 36 and 38 The overall quality outcome for these standards is good. 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 her responsibilities fully. Various quality assurance systems are in place. Service users financial interests are safeguarded. A system of supervision is being implemented. The health, safety and welfare of service users and staff are promoted and protected. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager is a first level nurse who has attended a variety of management training courses. Staff and service users both described her as friendly, balanced and approachable. It is recommended that the proprietors make supervision and support available to managers as well as care staff. Examination of records demonstrated that a variety of audits and satisfaction surveys are completed. It is recommended that the results of these be published for service users information. A sample of monies held on behalf of service users were checked and found to be accurate. Evidence of regular audit by the manager was also seen. Evidence of appraisal and supervision was seen. The system is fairly new, but good progress is being made. Notice of supervision is not always given. It is recommended that staff are given notice of supervision. Evidence of updated mandatory health and safety training was seen Maintenance records demonstrate that equipment is regularly serviced by external contractors. Chemicals are stored in separate cupboards. Risk assessments are undertaken and a record of accidents, injuries and diseases is kept. It is recommended that a more detailed audit of accident records be made. Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 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 3 2 2 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 2 X X X X 3 STAFFING Standard No Score 27 2 28 1 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 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 OP1 Regulation 5 (2) Requirement A copy of the service user guide that includes details of the complaints procedure must be supplied to each resident. Repeat Requirement All members of staff who handle food must be trained in food hygiene Repeat Requirement The providers and the management must continue to promote and provide training opportunities for staff to undertake NVQ accreditation Repeat Requirement The needs assessment should take account the compatibility of the service user to the service user group that they are joining The improvements to care records for each service should be maintained and expanded. The homes management must continue to actively monitor care practice to ensure that there is no recurrence of recent issues DS0000044398.V302766.R01.S.doc Timescale for action 31/08/06 2. OP15 18 (1)c 31/08/06 3. OP30 18 (1) a b c 31/12/06 4 OP3 14 31/07/06 5 6 OP7 OP10 17 12 31/07/06 31/07/06 Dussindale Park Nursing & Residential Home Version 5.2 Page 25 7 OP14 12, 16 8 OP18 37 9 OP29 19 10 OP21 23 11 OP30 12 12 OP16 21 13 OP7 17 relating to poor care practice. A reliable method of identifying service users clothing to ensure that it is returned to them after laundering must be achieved. The Commission must be notified immediately of all serious events relating to the health, safety and well being of service users. No member of staff should commence working without having a CRB check in place. Unless they are under constant supervision in line with Department of Health POVA1 guidelines. Suitable storage must be provided to prevent bathrooms being used for inappropriate storage of wheelchairs, commodes and other unsuitable items. The manager must maintain the recent positive steps taken to improve communication, staff relationships and training within the home. The positive support and assistance given to staff to enable safe and supported whistle blowing should be continued by the organisation. The update of care plans into one format must be completed 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/10/06 Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 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 2 3 4 5 6 7 Refer to Standard OP7 OP8 OP9 OP12 OP13 OP15 OP16 Good Practice Recommendations Care notes should be recorded in one place rather than in an assortment of records. Management should monitor the regularity of access to bathing for all service users. Staff administering medication should check with service users their pain relief requirements at all times. Consideration should be given to providing more intellectually stimulating activities, and 1:1 sessions with service users where possible. Photographs of the management team should be available so that service users and their visitors can easily identify them. A wider variety of fresh foods, food types and dishes should be made available. The home should record minor complaints, comments and suggestions as well as compliments about the service to provide a wider range of information to audit the homes response. The manager should implement a system to monitor the frequency of inappropriately sorted linen given to the laundry. Dementia care training should be given to all staff. The manager should be offered appropriate professional supervision and support by the proprietors. Results of satisfaction surveys should be given to service users. Staffing levels should be monitored to ensure that service user needs are met. Positive information about different cultures should continue to be given to enhance staff and service user knowledge. Staff should be given notice of supervision. A more detailed audit of accidents should be made. 8 9 10 11 12 13 14 15 OP26 OP30 OP36 OP33 OP27 OP27 OP36 OP38 Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dussindale Park Nursing & Residential Home DS0000044398.V302766.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!