Inspection on 03/05/06 for Gillibrand Hall Nursing Home

This inspection was carried out on 3rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Gillibrand Hall Nursing Home 11/03/10

Gillibrand Hall Nursing Home 18/01/10

Gillibrand Hall Nursing Home 02/06/09

Gillibrand Hall Nursing Home 02/07/07

Gillibrand Hall Nursing Home 03/02/06

Gillibrand Hall Nursing Home 04/08/05

Gillibrand Hall Nursing Home 31/01/05

Gillibrand Hall Nursing Home 19/08/04

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

CARE HOMES FOR OLDER PEOPLE Gillibrand Hall Nursing Home Grosvenor Road Chorley Lancashire PR7 2PL Lead Inspector Anne Taylor Unannounced Inspection 09:00 3rd May 2006 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 Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gillibrand Hall Nursing Home Address Grosvenor Road Chorley Lancashire PR7 2PL 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) 01257 270586 Century Healthcare Limited Ms Joan Lilian Calf Care Home 50 Category(ies) of Dementia (31), Old age, not falling within any registration, with number other category (31), Physical disability (6) of places Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 50 service users to include: Up to 31 service users in the category OP (Old age, not falling into any other category) Up to 31 service users in the category DE (Dementia) Up to 5 service users in the category PD (Physical Disability) aged 55 years and above. The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. One named service user in the category PD (Physical Disability), aged 50 years and above, may be accommodated within the overall number of registered places. 3rd February 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Gillibrand Hall is a listed building, set in its own grounds, within a residential area close to Chorley town centre. Public Transport does serve the area nearby but access to the home is via a public right of way and a long driveway . The home provides care for up to fifty residents of either sex with a range of nursing and personal care needs. At the time of inspection forty-three people were living at the home. Accommodation is set on two floors. Currently, the ground floor offers accommodation for residents who require nursing or personal care and the first floor for residents who suffer from dementia. The first floor is served by a passenger lift . A number of rooms are equipped with en-suite facilities and both floors have enough communal space. Residents have use of an enclosed courtyard, which is furnished with appropriate garden furniture. As of April 2006 the fees at Gillibrand Hall range £353.50 to £452.00. Information about the facilities and services provided can be found in the home’s statement of purpose and service user guide. A website is also Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 5 available to anyone with access to the internet. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 9am, lasted eight hours and was carried out by two inspectors. All of the key standards were assessed and progress on requirements and recommendations made at the last inspection was monitored. The inspection focussed on outcomes for residents. It involved discussion with the people who lived and worked at the home and visitors, examination of records, policies and procedures and a tour of the premises. There have been no complaints about this service since the last inspection. One allegation of suspected abuse has been reported and appropriate action in relation to this has been taken by the home. What the service does well: What has improved since the last inspection? The standard of record keeping in relation to care planning is greatly improved and needs are clearly identified; this helps the care process and promotes the welfare of residents. The number of staff achieving external accreditation for a qualification in care has increased and the knowledge base of those carers has therefore improved. Adult protection issues are managed in a way that makes sure the safety and well being of residents is central to the aims and objectives of the home. Staff Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 7 have received appropriate training and polices and procedures reviewed and updated. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 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 Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process is generally satisfactory but more effort is needed to make sure that the home’s policy and procedures in relation to the preadmission and admission processes are consistently adhered to. EVIDENCE: The service has developed a statement of purpose, which sets out the aims and objectives of the home and a service user guide that provides basic information about the service. The guide is made available to residents in a standard format and copies of both documents are kept in residents’ rooms or in communal areas of the home. Both the documents are not up to date and do not reflect the current arrangements in the home, for example the name of the present manager and other key staff. The home has developed detailed statements of terms and conditions of residency that cover long term and short term periods of residency. The home’s policy is to make sure that prospective residents, regardless of the Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 10 source of funding, receive a copy of this statement, along with a copy of the service user guide prior to moving to he home. However, records showed that a number of new residents had not received the statement of terms and conditions or the service user guide so they might not be clear about the service they will receive. Evidence suggests that prospective residents have a needs assessment carried out before they are admitted to the home to make sure that individual needs can be met. The home has received copies of the summaries and care plans from those assessments carried out through care management arrangements for most residents. For residents that are self funding the home is able to show that they have undertaken an assessment and that the assessments are generally satisfactory. Assessment forms used by the home have been developed to show when residents or a representative are involved in the assessment but in some cases the section of the form was blank and it was not clear whether they have been given the opportunity to be involved or not. Staff are briefed on the needs of new residents and an individual care plan is developed for each resident based on the initial assessment. The plans reflect the needs of the individual taking into account religious and social preferences where possible. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 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 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that residents receive is satisfactory and based on their individual need. However, the principles of respect, privacy and dignity are not consistently put into practice. EVIDENCE: Each resident has a plan of care but practice in involving residents or their representative in the development and review of the plan is variable. The plans include information necessary to plan individual care and risk assessments for most safe working practices are in place. The use of bed rails needs to be more effectively risk assessed to ensure the continued safety and well being of residents. An appropriately trained person determines the amount of trained nurse input needed for residents receiving nursing care and the information is accessible to all care staff. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 12 Evidence of updating information and changing actions appears on care plans and some relatives confirm their involvement in developing and reviewing the plan. Care practices are supported by policies procedures and practice guidance so that staff are clear about what is expected of them and are familiar with best practice. There is evidence in the care plan of health care treatment and intervention and a record of general health care information so that individual health care needs are identified and instructions for staff to manage those needs are clear. Residents’ health is monitored and appropriate action taken when needed. Staff seek advice from other health care professionals when required and act upon it. The home is able to provide or access aids and equipment needed to help with the management of health care needs. The home works to an efficient medication policy, supported by procedures and practice guidance so that the handling of medication is safe. Staff are aware of and understand the guidance and quality assurance systems confirm that practice reflects policy. Staff follow robust systems to make sure that medication records are fully completed, contain required entries and are signed by appropriate staff. Regular management checks are recorded to monitor compliance. The home has policies and procedures that cover the rights of residents including the right to respect, privacy and dignity and the home’s policy is to make sure these topics are covered during induction. However implementation of the home’s induction training programme is inconsistent and feedback from senior staff and relatives suggest that not all care staff are familiar with ways of respecting the privacy and dignity of the people they care for and do not consistently promote the rights of residents in relation to this aspect of their care. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 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): 12,13,14,15 The quality outcome for this area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make choices about their lifestyle, social activity and keep in contact with their family and friends. Social and recreational activities meet residents’ expectations. Residents receive a healthy varied diet according to their assessed need and choice. EVIDENCE: The routines of the home are planned around residents’ needs and wishes. Systems in the home enable the service to be flexible and changed to meet individual wishes and residents are encouraged and helped, wherever possible to make choices about the activities of daily living. Staff listen to residents and try hard to provide a flexible service, which helps them to enjoy a better quality of life. Individual staff are involved in one to one or group discussion with residents and staff resources are provided to allow time for resident activities and stimulation. The home operates a key worker system, which enables closer resident staff relationships where likes and dislikes are shared. Key workers try to use the information to plan activities, which residents will enjoy. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 14 Family and friends feel welcome and know they can visit the home at any time. Staff make time to talk to visitors and share information if agreed with the resident. The design of the home provides seating areas within the communal areas of the home where residents can meet their visitors, in addition to meeting them in the privacy of their own rooms. Staff will support those residents who need help in financial matters and work to a robust policy that protects residents form financial abuse and directs staff in their practice. The home is able to offer information and telephone numbers to residents for contacting independent people who will act as advocates on heir behalf. Residents have the choice to bring goods into the home and are encouraged to keep personal items that are important to them in their own room. The food in the home is of good quality, well presented and meets the dietary needs of residents. The cook is experienced and tries to meet the preferences and suggested dishes when preparing the menus. Staff help those residents who need help when eating and are sensitive in their approach. Residents enjoy the flexibility of meal arrangements and enjoy being able to eat in their own room if they wish. Regular dinks and snacks are available and staff will always make a cup of tea at anytime when asked. Tables are set attractively with necessary cutlery and aid to help individuals during their meal. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 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, 18 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a robust complaints procedure, and satisfactory arrangements are in place to protect them from abuse. EVIDENCE: The home has an up to date complaints procedure that meets the National Minimum Standards and Regulations. The complaints procedure is displayed within the home and residents and others associated with the provision understand how to make a c complaint. A copy of the complaints procedure is included in the service user guide and the home’s policy is to provide each prospective resident with a service user guide before they come to live at the home. Polices and procedures regarding protection are satisfactory and have recently been reviewed and updated in line with regulations and other external guidance. Within the policy it is clear when incidents need external input. Links with external agencies are satisfactory and includes CSCI, police and adult protection teams. Staff can demonstrate an awareness of the policy and know what immediate action to take and when and who to refer any incident to. Training has been provided for all staff so they are up to date with legislation and current best practice. The outcomes from any referral are satisfactorily managed, with Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 16 issues resolved. Residents and others associated with the home say that they are satisfied with the service provision and feel safe and supported. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 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): 19,26 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment. EVIDENCE: The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. It is a very pleasant, safe place to live with rooms that meet the national minimum standards or are larger and some have en-suite facilities The specialist unit for people with care needs associated with dementia offers a secure and homely environment, Residents are able to walk round the unit without restriction and also have supervised access to the secure inner courtyard/garden/patio area in nice weather. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 18 There is a designated maintenance person and a rolling programme of maintenance and repair. Where rooms are shared it is only by agreement and screens are provide for privacy. Residents are given the choice to move into a single room when one becomes vacant. They have the choice to bring personal items of furniture into the home and the fixtures and fittings meet the needs of residents and can be changed if their needs change. There is a choice of bathing facilities, both assisted and unassisted showers and baths and there are a number of toilets placed strategically around the home. Residents say there is plenty of hot water and the temperature of the home is usually fine and can be changed, on request in their own rooms. The home is well-lit clean, tidy and most of the home smells fresh. There is an unpleasant aroma in some parts of the specialist dementia care unit, despite regular cleaning of all the carpets and soft furnishings. The home has an infection control policy that needs updating to reflect current best practice. Staff are encouraged to work to the home’s policy and implement infection control procedures to help reduce the risk of infection. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 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): 27,28,29,30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are employed in sufficient numbers to meet the aims of the home and meet the changing needs of residents. Training lacks structure and organisation so that staff do not consistently receive up to date training that will help them to do their jobs more effectively. EVIDENCE: Residents are generally satisfied the care they receive meets their needs but there are times when there is no one available to immediately help them. They feel that staff are able to deliver their care needs and staff will go out of their way to try and help them. The service recognises the importance of training but does not consistently deliver a programme that meets statutory requirements and the national minimum standards. There is a training matrix and staff appraisal system that should allow the home to recognise when additional training is needed, but it is not properly and consistently managed. As result not all staff receive training appropriate to their needs and are always provided with up to date guidance that will help them maintain best practice. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 20 Staff are encouraged to undertake external qualifications and more than fifth per cent of care staff have obtained a recognised care qualification. Staff are clear about their roles and what is expected of them. Residents report that staff know what they are meant to do and that they are helped with all aspects of their care. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice and the service recognises the importance of effective recruitment procedures in the delivery of good quality services and the protection of residents. Staff recruited confirm that the service was clear about what was involved at all stages and was robust in following its procedure. There is currently little use of any agency staff. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 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): 31,33,35,38 The quality outcome for this area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is inconsistent. And the registered manager does not properly develop the quality assurance systems. EVIDENCE: The registered manager is a qualified nurse and has the experience necessary to run the home and is aware of the key processes set out in the National Minimum Standards. The home has a statement of purpose that sets out the aims and objectives of the service. Training, development and supervision of staff is inconsistent and the manager does not ensure that quality assurance monitoring is properly regarded or implemented as a core management tool. Although regular monitoring visits Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 22 are carried out by the responsible individual copies of the reports are not regularly submitted to the Commission. Current management processes do not ensure that staff receive feedback on their work and training needs in relation to safe working practices are not consistently identified. Mandatory training in relation to health and safety is therefore not all ways provided in a timely and structured manner. The home has developed a health and safety policy that generally meets health and safety requirements and legislation. It is aware of areas where they need to make improvements and has a plan for undertaking the work. Health and safety records are of a good standard and are routinely completed and action is taken if any problems are identified. The registered person is aware of the need to plan the business activity of the home and manage resources to deliver the business plan. The service provider tales responsibility for the home’s accounts and business development and has adequate insurance cover. Residents have the opportunity to manage their own finances if they wish and facilities are provided to help keep it safe. Where the home manages money on residents’ behalf a system is in place to record transactions and accounts for spending. Checks show that records are up to date and entries clear so that there is a full audit trail of income and expenditure. Residents are generally satisfied with the arrangements for managing their money. The service understands the need to meet external requirements where it acts as agent or appointee for residents. Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X 2 Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 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 6 Requirement The statement of purpose and service user guide must be kept under review and where appropriate revised. The registered person must notify the commission and residents of any such revision within 28 days. The registered person must ensure that each resident receives a copy of the home’s service user guide. The registered person must ensure that each resident receives a standard form of contract for the provision of services and facilities. Prospective residents or their representative must be given the opportunity to be involved in the pre admission assessment. (Timescale of 31/03/06 not met). A written plan of care as to how a residents needs are to be met must, wherever possible be drawn up and reviewed with the involvement of the resident or a representative. Timescale for action 30/06/06 2. OP1 5 30/06/06 3 OP2 5 30/06/06 4. OP3 14(1) 30/06/06 5. OP7 15(1) 30/06/06 Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 25 6. OP8 13(4)(c) Risk assessments in relation to the use of bed rails must be carried out consistently and reviewed regularly. Arrangements must be made to ensure that the home is conducted in a manner that respects the privacy and dignity of residents. (Timescale of 31/03/06 not met). Arrangements must be made to keep all parts of the home free from offensive odours. (Timescale of 31/03/06 not met). All staff must receive induction and ongoing training that will equip them with the skills and knowledge they need and keep them up to date with best practice. A detailed training programme must be developed that shows how the home is going to do this. (Timescale of 30/04/06 not met). The registered person must ensure that the home’s system for reviewing at appropriate intervals and improving the quality of care provided at the home is properly maintained. (Timescale of 30/04/06 not met). The registered person must ensure that a copy of the monthly quality assurance visit undertaken by the director of nursing is submitted to the Commission every month. The registered person must ensure that persons working at the care home are appropriately supervised. DS0000025560.V287147.R01.S.doc 31/05/06 7. OP10 12(4)(a) 30/06/06 8. OP26 16(2)(k) 30/06/06 9. OP30 18(1)(c) 31/07/06 10. OP33 24(1) 31/07/06 11. OP33 26 31/05/06 12. OP36 18 31/08/06 Gillibrand Hall Nursing Home Version 5.1 Page 26 13. OP38 18 The registered person must make sure that staff receive training appropriate to the work they perform including sage working practice topics. 31/08/06 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 OP26 Good Practice Recommendations Policies and procedures in relation to the control of infection should be updated to reflect changes in legislation and best practice. The registered manager should complete a recognised management course. 2. OP31 Gillibrand Hall Nursing Home DS0000025560.V287147.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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. 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