Inspection on 28/04/05 for Grey Ferrers Nursing Home

This inspection was carried out on 28th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Grey Ferrers Nursing Home 17/05/09

Grey Ferrers Nursing Home 22/05/08

Grey Ferrers Nursing Home 11/12/07

Grey Ferrers Nursing Home 02/07/07

Grey Ferrers Nursing Home 05/07/06

Grey Ferrers Nursing Home 20/09/05

Grey Ferrers Nursing Home 02/08/04

Grey Ferrers Nursing Home 06/05/04

Grey Ferrers Nursing Home 03/03/04

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

CARE HOMES FOR OLDER PEOPLE Grey Ferrers Priestley Road Off Blackmore Drive Leicester LE3 1LQ Lead Inspector Gillian Adkin Unannounced 28 April 2005 09:00 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 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. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Grey Ferrers Address Priestly Road Off Blackmore Drive Leicester LE3 1LQ 0116 2470999 0116 2558364 allsopp@bupa.com Bupa Care Homes Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Michael Allsopp Care Home 120 Category(ies) of DE(E) Dementia - over 65 (60) registration, with number OP Old age (30) of places PD(E) Physical disabilities - over 65 (30) Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Bradgate Unit may accommodate a total of 30 persons who fall within categories/combined categories OP and PD(E). Brandon House may accommodate a total of 30 persons who fall within categories/combined categories OP and PD(E). No person falling within either category OP or PD(E) may be admitted to the Home when an overall total of 60 persons who fall within those categories are already accommodated within the Home. To be able to admit the named person in category DE under 65 named in variation application numbered AN43335 dated 18/02/03. To able to admit named service user who falls within category MD(E) subjection of Variation No. 55305 dated 13 September 2003. To be able to admit a named service user who falls within category PD named in Variation No. 6583 dated 28 April 2004. Date of last inspection 2nd August 2004 Brief Description of the Service: Greyferrers is a 120-bedded care home providing personal and nursing care for older persons. Accommodation is provided within four separate units, these are known as Brandon, Bradgate, Stewards Hay and Woodville. Brandon is occupied by older persons requiring residential care, Bradgate by older persons requiring nursing care, Stewards Hay and Woodville provide care for older persons with dementia. Each unit is comprised of a large dining/ lounge area, a small quiet lounge, toilet, washing and bathing facilities and single room private accommodation. The home is located on the outskirts of Leicestershire and is easily accessed by public transport from the City of Leicester and from the County. The home provides nursing and residential care for service users whose care needs fall within the categories of Older Persons and or Physical Disability and Dementia over 65 years of age.The home is purpose built and is accessible to service users with disabilities. Accommodation is located on the ground floor. Each unit has a spacious lounge and adjacent dining area, which look out the gardens. All bedrooms are single occupancy and all are ensuite, many open directly onto the garden. The home is currently managed by a registered nurse and employs Registered General nurses, Registered Mental Health nurses and care staff. The home has ample parking and is close to a number of social amenities. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected for the tenth time against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over one day and commenced at 9.00 am on 28/04/05.The registered manager facilitated the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting four residents and tracking the care they received through review of their records, discussion with them, and their relatives, care staff and observation of care practices. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. This inspection was conducted in Stewards Hay unit and Bradgate unit. During this inspection a tour of the home took place and the inspector viewed internal records, and care plans. She also spoke to nurses, care and ancillary staff, residents (where practicable) and relatives. Discussions with the registered manager regarding requirements made at the last inspection (relating to Brandon and Woodville unit) indicated that eight out of ten requirements and all recommendations had been met. What the service does well: The home provides specialist care in two units for residents with Dementia. One for nursing and one for residential care. Stewards Hay provides a comfortable calm environment, which is conducive to this type of resident. The home employs two activities organisers who provide a good range of activities (including external trips ), which meets the needs of the diverse resident group in the home. Staff on Stewards Hay have worked with the activities organisers to incorporate an evening activities session where all staff take part for one hour after tea. Residents who cannot take part in-group activities are included in one to one sessions. The service has an excellent quality assurance system in place, which includes internal audits, regular meetings with management and the “Personal Best Programme” which BUPA have recently introduced. The programme is a Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 6 behavioural programme for staff. A significant investment has been made in the programme by BUPA to ensure that all staff are working in the same manner which supports best practise. Staff spoken with and observed during this inspection were noted to be friendly and caring towards residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 7 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 Standards Statutory Requirements Identified During the Inspection Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 8 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 standard(s) 3.4 Comprehensive assessment of individuals prior to admission and consideration of all healthcare needs ensures that residents and their relatives are confident that the home will meet their individual needs. EVIDENCE: Four residents were case tracked on this occasion. Two were from each unit Stewards Hay and Bradgate.Although all four care plans included a comprehensive BUPA assessment one care plan did not contain an initial assessment from the funding authority and therefore it could not be concluded if the care plan was reflective of the residents needs. Admission documentation in one care plan was not fully completed and a number of essential risk assessments were not included. The two units are staffed with registered general nurses and registered mental health nurses both of which are trained to meet the individual needs of residents accommodated in these units. All care plans tracked included evidence of external professionals involved in residents care. A relative interviewed stated “the home keep me up to date with changes and consider that my wife’s healthcare needs are well met in the unit” Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 9 Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 10 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 standard(s) 7.8.9.10 Robust care planning and evaluation and appropriate management of medication ensures that healthcare needs are fully met and that residents are not placed at risk of harm or risk through omissions. EVIDENCE: Four residents care plans were case tracked. Two residents had high dependency nursing needs as detailed in assessments and two had mental health needs. Risk assessments in two care plans were not in place. The outcome that staff would not be fully aware of management of behaviour in one case and moving and handling in another. A diabetic care plan had not been evaluated for three months, which could place the resident at risk of harm. Where residents were nursed in bed, staff had completed positional change charts ensuring comfort and appropriate pressure area care. Discussions with staff on the Dementia care unit identified that regular toileting regimes were in place and were well documented this ensures residents’ dignity was maintained. Discussions with relatives in both units and observation of care given by staff confirmed that residents were treated with respect and dignity. Staff members are well motivated in providing a high quality of care. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 11 One resident tracked had a pressure area which had been photographed by staff. Documentation contained in the care plan did not evidence outcomes in terms of wound healing. A nursing resident on Bradgate unit was tracked and medication was inspected. Good evidence was given of pain management and medication had been administered appropriately and according to the prescriber’s instructions. Requirements were made regarding the evaluation of care plans and risk assessments. Care plans on Bradgate unit were more robust and better maintained than on Stewards Hay and were more reflective of outcomes. Two instances were noted on Stewards hay unit where medication had not been appropriately signed for, one being for an antipsychotic medication which is prescribed to manage the residents mental health needs. All other areas of medication administration on both units were appropriately managed and discussion with staff confirmed that only registered general nurses are responsible for the administration and ordering of medication. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 12 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 standard(s) 12.13.14.15 Giving residents’ choices over their daily lives and ensuring that they experience a homely life, which includes flexible routines, good quality meals and appropriate activities, and includes their relatives and friends input ensures that the experience of living in the care home matches their expectations and individual requirements. EVIDENCE: None of the residents’ case tracked on this occasion had any specific cultural or religious requirements. However discussions with the activities organiser and staff in both units confirmed that routines are flexible and do reflect residents needs. In Stewards hay unit for example where residents have Dementia, staff stated that although routines are vital and were observed throughout the day, a specific time had been set aside for one to one activities which included all staff members after tea time. This was considered good practise and reflected person centred care. The activities organiser provided four sessions of activities including one to one sessions on Bradgate unit for residents nursed in bed. Both units inspected were considered to be homely and welcoming and were conducive with those accommodated in them. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 13 Comments received from relatives and friends during the inspection were very positive and included: ” Staff keep me informed of any changes they are very good at that” “The staff organise all things for my wife like chiropody and eye tests etc” “ Things have been very good so far my mum has only been here a short time though” The midday meal was observed being served in on of the two units Meals being served appeared well balanced and fresh. Individual preferences are catered for and where residents cannot make choices, likes and dislikes are noted on admission and referred to the kitchen. Residents and relatives spoken with said that they enjoyed their meals and although a set mealtime is in place they are able to have meals at different times to meet their individual schedules and by prior arrangement. Care plans seen included specific dietary advice as directed by the dietician and staff spoken with were aware of these individual needs. A relative stated “Meals are of very good quality overall”. Residents tracked with specific nutritional care needs were fully documented in their care plans and risk assessment was in place where resident had been identified with a choke risk. Staff spoken with were aware of the feeding requirements and risks associated with this person and were observed by the inspector to be assisting them in a satisfactory manner. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 14 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 standard(s) 16.17.18 Complaints are managed efficiently and responded to within given time scales. There is an adult protection procedure to respond to suspicion or allegation of abuse. EVIDENCE: Examination of the written complaint procedure indicated that clear guidance is given to residents and their relatives on how to make a complaint on admission to the home. A copy of the complaint process is posted on the wall in the reception area of the home and in each unit. No complaints were under investigation at the time of inspection. Only one of the three residents tracked indicated that they knew how to make a complaint (due to their medical condition). Relatives spoken with identified either the unit manager or a senior member of staff whom they would direct a complaint towards. Examination of the written adult protection process indicated that procedures are in place to respond to allegations of abuse. Several staff members spoken to were able to verbally demonstrate their knowledge of the home’s adult protection process. The registered manager has experience of referral and management of vulnerable adult situations. Two staff on one unit however stated that they had not received any adult protection training recently and both had no knowledge of the multi agency prevention of abuse policy “No secrets” Two residents spoken to indicated that they felt safe in the home. Other residents spoken with were unable to answer questions. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 15 Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 16 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 standard(s) 19.22.23.24.26 Clean, safe and well maintained living areas and rooms which are personalised to reflect residents’ individual tastes, and provision of appropriate equipment and adaptations ensure that residents live in surroundings which maximise independence and are comfortable and homely. EVIDENCE: Both units were noted to be clean and well maintained and appear to meet residents’ needs. Both are decorated and furnished to a good standard which creates a comfortable and homely environment. Plans are in place for redecoration on the unit this year and bedrooms are redecorated as they become vacant prior to a new resident moving in. There is an ongoing system of maintenance and refurbishment. The garden area is accessible to residents who are in wheelchairs Residents’ rooms are clean, well decorated and residents are able to bring items of their own furniture and possessions with them to personalise their rooms. Many of the rooms have en suite facilities and specialist equipment such as hoists, profiling beds and pressure-relieving mattresses were seen in use. The registered manager has purchased two new hoists and another one Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 17 has been ordered since the last inspection. Staff were observed to respond to call bells promptly. There is a spacious sitting room and dining room on the ground and on the first floor, with a conservatory on the ground floor- used as a smoking roomoverlooking the garden, offering a range of communal accommodation. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27.28.29 The number of staff deployed to work in the two units is sufficient to meet residents’ basic care needs. Where specialist care needs are identified staffing levels and additional training would ensure that holistic care needs are fully met and are person centred. EVIDENCE: Staffing hours were calculated on each unit separately. Staffing hours provided on the nursing unit (Bradgate) were 749 care hours, which include all, nursing staff. The home was therefore complying with the number of hours as recommended by the department of Health’s Residential Forum. A calculation of staff hours on Stewards Hay unit demonstrated that although providing 742 care hours which complies with recommended minimum staffing hours dependency levels of residents on this unit is significantly higher and in order to meet the individual needs of residents with Dementia an additional member of staff would improve service delivery and outcomes for individuals. This was further supported by observation of staff at work during the inspection. Residents on this unit require continuous input from staff, which cannot be met with current staffing hours provided. Trained staff described the difficulties they have and the potential risks to residents in managing those who require attention whilst administration of medication takes place and the drug trolley is open. It is considered that it would be advantageous and reduce potential risk if two staff were able to undertake the medicines round together and it is further considered that an additional member of staff on both the early and late shift Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 19 would improve the ability for staff to provide individual attention to residents who require one to one attention at certain times of the day. Discussion with relatives demonstrated that staffing has been fluid recently and discussion with the registered manager confirmed that there has been considerable staff movement since the last inspection. The registered manager was aware of the difficulties regarding staffing levels on Stewards Hay unit and was proposing to address this after this inspection with senior managers. Discussions with staff on one unit indicated that no training (other than mandatory training) had been supplied this year by the registered provider for staff. Staff considered that they should receive training in Dementia, and challenging behaviour in order to maintain current good practise. One of the units inspected is a specialist Dementia care unit it and it is vital in terms of resident outcomes that staff are fully trained. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32.36.37 38 The registered manager and unit managers demonstrate good leadership within the home. The appointment of a deputy manager will ensure that outcomes for them are improved. Regular supervision of staff by unit managers would further ensure that the quality of care is maintained and staff are fully developed in their role. Identification and assessment of personal risks will ensure that residents are protected from harm or danger. EVIDENCE: The home is a large multi site home and consists of four separate units accommodating different categories of resident. Each unit has a unit manager and deputy manager and the home has one registered manager to oversee the service. Senior staff are expected to take charge of the site out of office hours. There is an on call manager on duty who is accessible for emergencies. The registered manager and unit managers on the units inspected are all registered general nurses or registered mental health nurses. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 21 Staff and service users spoken with were able to identify the unit managers and most relatives were aware of who the registered manager was. Discussions with relatives indicated that both units were well run and that unit managers were approachable and pleasant. Both units inspected had a friendly and welcoming feel to them. Discussions with staff and with the registered manager and observation of records indicate that although supervision of some staff has taken place since the last inspection, it was inadequate and inconsistent. Records inspected overall were of an acceptable quality and as part of a quality audit BUPA have recently commenced auditing of staff files. Care plans were of a reasonable quality overall and requirements have been made where deficits were identified. Daily records inspected identified that an accident which had occurred overnight had not been reported to the registered manager or documented in accident records Staff on the unit stated that this was not uncommon particularly in relation to nights. Two incidents were identified by the inspector which had not been reported to the Commission for Social Care Inspection under Regulation 37 and the manager was unaware of either incident. One care plan contained photographic evidence of wounds, which was easily visible to persons reading the care plan and were not stored in accordance with Data protection. The outcomes of which were that resident’s dignity and privacy was impaired. Management of risks identified within the initial assessments of two residents tracked had not been fully addressed in risk assessments, these included moving and handling of one resident also risk of absconsion and behavioural management of another. Failure to address these risks could result in individuals concerned and others persons being placed at risk of harm. Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x 3 3 3 N/A 3 STAFFING Standard No Score 27 3 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 x 3 x x x 2 2 2 Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 23 Are there any outstanding requirements from the last inspection? 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 36 Regulation 18 Requirement The registered manager must improve the method and frequency of supervision in each unit. The registered manager must keep adequate records to demonstrate that supervision is being conducted six times per year. The registered manager must improve the system of notification of Regulation 37 to the Commission. This must include internal monitoring of incidents. The initial assessment of a prospective resident must include the assessment undertaken by the Social worker or funding authority.This assessment must be kept in the care plan. Care plans and associated risk assessments must be comprehensive and detail all healthcare needs and risks including risk of falls and restraint. Plans and risk assessments must be evaluated at least monthly and must demonstrate resident/ relatives Timescale for action 20th June 2005 20th June 2005 2. 36 18 3. 38 37 21.04.05 4. 3 14 21.04.05 5. 7 13.15 20th June 2005 Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 24 consultation 6. 8 12 Staff with responsibility for management of pressure area care must be provided with regular tissue viability / pressure area care training. This must be monitored by the registered manager and evaluated as part of staff training/ supervision. The manager must make appropriate arrangements in each unit to monitor the medication system in both unitsand to identify areas of concern All staff including bank staff and ancillary staff must attend adult protection training. All staff including bank staff and ancillary staff must attend training specific to the client group for which they are caring,this must include Dementia Care and management of challenging behaviour. Confidential or sensitive information such as photographic evidence of wounds must not be stored in documents which are accessible to non nursing/care staff. Arrangements must be made for storage which complies with the Data Protection Act 1998 All risks associated with individuals must be fully addressed in a risk assessment this includes moving and handling verbal aggression,absconsion from the home.Assessments must be evaluated as often as deemed necessary according to risk presented and possible outcomes for individuals. 21.04.05 7. 9 13 21.04.05 8. 9. 18 28 13(6) 18 30th August 2005 30th August 2005 10. 37 17 21.04.05 11. 38 13.37 21.04.05 Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 25 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 27 Good Practice Recommendations It is recommended that staffing levels on Stewards Hay unit are increased to reflect the categories of resident accomodated and are refelctive of guidance as recommended in the Department of Healths Residential Forum for persons with mental health It is recommended tha t tadmission documentation is fully completed within at least seven days of admissionof the resident. It is recommended that tissue viavility care plans detail the pressure required on the alternating pressure mattress according to manufacturers instructions. It is recommended that consideration is given to the risks associated with administration of medicines on Stewards hay unit and that consideration is given to the use of two persons to undertake drug rounds to prevent errors. It is recommended that all staff are instructed to familiarise themselves with the multi agency policy No Secrets. It is recommended that the consideration is given to the provision of cushions in both units inspected It is recommended that consistency of staff is maintained in the Dementia Care units to ensure continuity of care for residents. It is recommended that at least a ten year work history is obtained on all application forms and that gaps in work history are explored and documeted at interview. 2. 3. 4. 7 8 9 5. 6. 7. 8. 18 24 27 29 Grey Ferrers C51 S1907 Grey Ferrers V221442 210405.doc Version 1.20 Page 26 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park, Enderby Leicestershire LE19 1SX 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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