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Inspection on 19/09/05 for Ingleby Care Home

Also see our care home review for Ingleby Care Home for more information

This inspection was carried out on 19th September 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Some environmental improvements have been made, such as new vinyl flooring in bathrooms, some redecoration of lounge areas and the laying of a new carpet.

What the care home could do better:

There are a number of areas, which have been identified, that need to improve. These relate to the individual resident`s documentation, assessment of need and care plans, which currently do not contain sufficient detail and do not fully demonstrate how social and health care needs are met.The environment continue to be in need of further improvement, this includes redecoration of a number of areas, improved bedroom furniture, replacement carpets and a replacement bath in one of the ground floor bathrooms. There is also the need to ensure that the recruitment procedures are fully followed at all times and that all staff received regular formal supervision. Whilst the staffing numbers are appropriate, it was noted that there was regular sickness within the staff team, which potentially has an effect on staff morale. Staff training is also in need of review and updating and a clear, up to date, detailed training programme is needed. The programme for in house regular recreational activities would benefit from further development. The review and updating of records such as policies and procedures needs to be completed and robust systems must be implemented particularly in relation to management of resident`s personal allowances. The Health and Safety systems such as fire training and fire drills need to be carried out more frequently and appropriately recorded.

CARE HOMES FOR OLDER PEOPLE Ingleby Nursing Home Lamb Lane Ingleby Barwick Stockton-on-Tees TS17 0UP Lead Inspector Jackie Herring Announced Inspection 19th September 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ingleby Nursing Home Address Lamb Lane Ingleby Barwick Stockton-on-Tees TS17 0UP 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) 01642 750909 01642 750966 T L Care Ltd Miss Margaret Little Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That a maximum number of 5 places may be used at any one time for the accommodation of persons who are 50 years and over with a physical disability. One named individual who is under the age category is allowed to reside in the home. One named individual who is under the age category is allowed to reside in the home for a period of respite care. 16th May 2005 Date of last inspection Brief Description of the Service: Ingleby Nursing Home is a 50 bedded purpose built care home which provide personal and nursing care. All 50 rooms are single rooms with ensuite facilities and there is the required number of bathing facilities and communal space. Ingleby is owned by TL Care who also operate a further four homes in the Teesside area. Ingleby Nursing Home is close to the centre of Ingleby Barwick, being in easy reach of the local church, supermarket and parade of shops. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an announced inspection and was completed by two inspectors over one inspection day, sixteen inspection hours in total. A range of records were examined, including staff files, residents assessments and care plans, policies and procedures and health and safety records. The pre inspection questionnaire was returned to CSCI prior to the inspection as were a number of resident’s surveys. A number of residents and staff were interviewed and there was discussion with the operations manager. A tour of the home also took place. A large number of requirements and recommendations have been identified during this inspection. It is acknowledged that there are many changes taking place and areas being developed within Ingleby Nursing Home. The Inspectors were satisfied that there is a great deal of commitment from the organisation to positively address and improve these areas. A number of areas were identified as requiring immediate action, the inspectors observed these matters being addressed as they were identified during the inspection. What the service does well: What has improved since the last inspection? What they could do better: There are a number of areas, which have been identified, that need to improve. These relate to the individual resident’s documentation, assessment of need and care plans, which currently do not contain sufficient detail and do not fully demonstrate how social and health care needs are met. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 6 The environment continue to be in need of further improvement, this includes redecoration of a number of areas, improved bedroom furniture, replacement carpets and a replacement bath in one of the ground floor bathrooms. There is also the need to ensure that the recruitment procedures are fully followed at all times and that all staff received regular formal supervision. Whilst the staffing numbers are appropriate, it was noted that there was regular sickness within the staff team, which potentially has an effect on staff morale. Staff training is also in need of review and updating and a clear, up to date, detailed training programme is needed. The programme for in house regular recreational activities would benefit from further development. The review and updating of records such as policies and procedures needs to be completed and robust systems must be implemented particularly in relation to management of resident’s personal allowances. The Health and Safety systems such as fire training and fire drills need to be carried out more frequently and appropriately recorded. 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. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 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 the following standard(s): 1, 2, 3 Residents are provided with terms and conditions that contain the required information. There is insufficient documentation to demonstrate that assessment of need took place prior to admission. EVIDENCE: The format of the statement of purpose continues to be in need of further development making is more accessible to residents. One of the standards was an outstanding requirement from the previous inspection. A copy of the terms and conditions of residency was made available for examination during the inspection. It contained all of the required information. During an examination of four sets of residents’ records, there was no evidence of any pre assessments carried out by the home and as such no judgement made about whether individual residents needs could be met. In the files examined, the assessment documentation was dated on the day of individual resident’s admission to the home. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 9 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 health and personal care needs are not sufficiently detailed in the care plans and do not fully reflect the residents current level of need. As such, the resident’s welfare is not fully promoted and safeguarded. Medication administration procedures are generally in order, however some improvement needs to be made in this area. EVIDENCE: Five sets of resident’s records were examined during the inspection, two of which were for nursing clients and three for residential clients. It was identified that the documentation for nursing and residential clients is different and that the documentation for the residential clients was new and had recently been introduce. Nursing and residential documentation was in need of more detailed information particularly in relation to assessment of needs and personal preferences. In two of the five files examined, the information was very sparse. The risk assessment tools such as handling assessments, pressure care, and nutritional assessments were in place however they did not contain sufficient detail. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 10 Where a high risk had been identified, for example one resident had been identified as at high risk of developing pressure damage, no care plan was in place. Although new documentation had recently been introduced for the residential clients, it did not contain up to date accurate information about the residents. In one set of records it stated that a resident was diet controlled diabetic, however on examining the medication records, it was identified that they were on oral medication for their diabetes. There were a number additional assessed needs missing from the individual residents assessments. It was also identified that residents’ weights were not recorded monthly and that the recording of baths and showers indicated that these were few and far between. It was identified that core care plans were being used in places, which had not been sufficiently personalised and did not fully relate to the care needs of individuals. Quite a lot of the documentation was not dated or signed and there was no evidence of the involvement of residents or their representatives in regard to their individual assessments and care plans. Of the five assessments and care plans examined, it was requested that one of the residents be reviewed by the GP and district nurse in respect of diabetes care and that the assessment of need and care plan be developed further with more specific direction in terms of care and care interventions. A recent visit had taken place by the Pharmacist Advisor and North Tees PCT and a small number of action points were raised, which are in the process of being addressed. The medication systems are in the main sound, however it was noted on the day of the inspection, that they quality of the Medication Administration Records were not good as in a number of the sheets examined, the first letter for each drug name was missing. It was agreed that this would be remedied swiftly. During discussions with residents they stated, “definitely treated as individuals, you get the attention you needs, always knock on the door before coming in”. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 11 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 Resident’s lives would be enhanced further by developments to the occupation, socialisation and activities programme. Open visiting is encouraged and residents are able to maintain contact with family and friends. EVIDENCE: During discussion with residents, they described how they were able to make decisions about their daily lives and exercise personal control. One resident stated, “I go out to play bowls twice a week and me and another resident go to the local café for a cup of tea”. One resident also said that life in the home was fairly flexible and said, “if I want to I can have a lie in”. Another resident stated that he made all of his own daily lifestyle decision and was able to bath or shower independently, when they wanted as long as they told the staff. Whilst it is extremely good practise for this level of control and decision making, it is recommended that risk assessments are in place for situations such as unsupervised showers and residents going to the local café. On the day of the inspection, a flower arranging morning was underway and residents were taking pride in their work. During discussion about recreation activities and occupation, it was agreed that this area was in need of further development and steps were underway to address this. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 12 Residents also confirmed that they were able to maintain links with friends and family. A group of friends, volunteers and family support the home through the residents amenity fund. They do a number of fundraising events such as a summer garden party and they organise a number of events throughout the year such as weekly coffee mornings, lunch at Marton Country Club and trips to Redcar and Northallerton. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 13 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 residents are generally protected, however further staff training is needed to increase knowledge and awareness. EVIDENCE: Residents and staff were aware of the complaint procedure and residents said, “no worries or concerns, if I had would speak to staff or manager”. The staff training programme was examined and there was no evidence that staff had received Adult Protection training. Through discussion with the Operations Manager, it was confirmed that further training was required on this topic and also the reporting of incidents, such as resident to resident’s altercations. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 14 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, 21, 24, 26 The environment at Ingleby is in need of further improvement to increase a safe, comfortable and homely place for residents to live. EVIDENCE: It is acknowledge that improvements have been made to the environment at Ingleby since the last inspection, further improvements are however needed. These relate to some of the bedroom furniture, as it was noted that some of the wardrobe cupboards do not stay closed without the use of elastic bands and the wood on a number of the pine side tables has split. It was also noted throughout the home that bars of soap were in use rather than liquid soap and that a number of paper towel holders were also needed. The operations manager confirmed that these had been ordered and would be in place very soon. It was noted on visiting a number of bedrooms that there were no light shades over the fluorescents strip lighting in the ensuite facilities. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 15 Redecoration is required to a number of areas, and it was confirmed that the main reception was going to repapered in the near future. The ground floor dining room was also in need of redecoration and would also benefit from having the carpet replaced as it was not coordinated and did not present a homely environment. The carpet in the conservatory also needed to be cleaned or replaced and it would be beneficial to have blinds fitted to the roof to diffuse the effect of the sun and the potential overheating. Improvements have been made to the bathrooms however; the ground floor peach bathroom continues to be in need of attention as the current bath is not suitable for use. The shower/hairdressing room also needs to be attention and if it is to continue to be used for hair washing the toilet and additional sink must be removed. The sluice rooms need to be sorted out and free from clutter and there were also in need of a good clean. The store in reception was also in need of attention, as it was overflowing from floor to ceiling with continence products. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The deployment and numbers of staff on all shifts in the main is appropriate, although there has been a sickness issue. Residents would benefit from some staff receiving more training to enhance the skill mix. Recruitment practice does not always protect residents and record keeping in respect of all new staff is not robust enough. EVIDENCE: A random sample of four staff files was examined and in the main contained the required information. In one of the files however, the Criminal Records Bureau check had been transferred from another care home and the appropriate references had not been obtained. It was also noted on a file that a disclosure had been made however it was unclear whether the correct company procedure had been followed in regard to the employment of this person. The duty rota was examined and it was confirmed that there is always a first level qualified nurse on duty 24 hours per day. It was also confirmed that there were usually eight care workers on duty during the day and seven for the late afternoon/evening. It was however identified that there was problems with sickness at weekends, which reduced the numbers of staff on duty. The issue is currently being addressed through the homes own staff policies. There was also discussion about the range of skills and experience within the staff team and it was agreed that the training programme for enabling care workers to become directly more responsible for the care provision of residential clients be fully implemented. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 17 The training records were examined and it was identified that some of the mandatory training was out of date, such as First Aid, Health and Safety, and Infection Control. Fire training was also not being carried out as frequently as needed i.e. twice per year for all staff. An outstanding recommendation from the previous inspection was that staff should receive more client specific training; to date this has not been implemented. The actual training programme and checklist was in need of updating as all of the information had not been collated and it was unclear as to the numbers of staff who had achieved their National Vocational Qualifications and the pre inspection questionnaire detailing this information did not agree with the information contained within the staff list and training programme. It is however acknowledge that a number of staff have the required qualification. Residents spoke highly of the staff team, they said, “the staff are lovely, they can’t do enough for you”. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 18 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, 35, 36, 38 The home currently lacks clear leadership, staff are not appropriately supervised and there are areas that need further development to ensure residents health and safety is fully promoted. Arrangements for handling residents’ personal allowance are not robust enough. EVIDENCE: At the time of the inspection, CSCI had been informed that there was to be a change to the management of the home, and that the post for registered manager had been advertised. Staff supervision was discussed and a schedule for formal supervision was made available for examination. Although the system has been developed, it has only partially been introduced and at the time of the inspection, not all staff had received supervision within Ingleby Nursing Home. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 19 A number of service and maintenance records were examined and previously identified; fire training needs to take place more frequently. It had also been identified that some of the Health and Safety training such as COSHH and Infection Control was in need of updating. A random sample of resident’s personal allowances and records were examined and it was highlighted that there were discrepancies with the balance stated on the transaction sheet and the actual amount contained in the individual money pouches. These discrepancies in the main were for very small sums of money. As the discrepancies related both to some residents having more money in their pouches and some having less and the balance of the difference being similar, it was agreed that an immediate investigation would take place and that the system for managing residents personal allowances would be reviewed. A quality assurance file was looked at and it contained details of a range of areas that had been assessed and detailed areas for development, although the actions to be taken were unclear. There was evidence of some customer satisfaction; it was identified that this could be developed further to include both positive issues as well as areas for development. Policies and procedures continue to be in need of review and updating, it was confirmed, that work was underway with this review. Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 20 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 3 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 x 2 X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X 2 X 2 Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 21 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 OP3 Regulation 14 Requirement Timescale for action 01/12/05 2 OP7 14 3 OP8 15 A pre admission assessment must be in place for all residents, which demonstrates that individual resident’s needs can be met. The assessment of need must be 01/12/05 developed further and include detailed information about individual residents needs and to include likes, dislikes and lifestyle preferences. The assessment must be up to date and reflect individual resident’s current needs. There must be evidence of residents/representatives involvement with individual assessments. The health care assessment tools 01/12/05 must be up to date and contain the appropriate information regarding assessment of individual need and must be supported, where necessary by detailed plans of care ensuring health care needs are being met and the relevant professionals are involved. Risk assessment tools, such as moving and handling and DS0000055360.V251013.R01.S.doc Version 5.0 Ingleby Nursing Home Page 22 4 OP9 13 5 OP18 13 6 OP19 23 7 OP21 23 8 OP24 16 9 10 OP29 OP30 18 18 pressure care must contained detailed information and plans of care must be developed, where risk has been identified. There must be evidence of residents/representatives involvement with individual assessments and care plans. The recommendations from the recent audit by North Tees PCT must be implemented and the quality of the Medication Administration Records must be improved. Staff must receive training on the topic of Protection of Vulnerable Adults and must be able to demonstrate their understanding of the process to follow should the need arise. The environment at Ingleby must be safe and well maintained. A redecoration programme must be developed that is realistic and timely and a copy of this forwarded to CSCI. The ground floor dining room carpet and conservatory need to be replaced. The shower room that is currently being used as a hairdressing salon must have the toilet and additional wash hand basin removed. The ground floor peach bathroom, must have the bath replaced. Some of the bedrooms furniture must be replaced or effectively repaired as it unacceptable to have elastic bands in place to keep cupboards closed and to have wooden furniture that has split. The recruitment procedure must be robust and as specified in regulation 18 and Schedule 2/4. All new staff who do not hold the DS0000055360.V251013.R01.S.doc 19/09/05 01/12/05 01/12/05 01/12/05 01/12/05 19/09/05 01/12/05 Page 23 Ingleby Nursing Home Version 5.0 11 OP26/ OP38 23 appropriate qualification must undertake the required induction and foundation training as detailed by Skills for Care. The two sluice rooms must be tidies up and given a good clean. The number of bins for used incontinent pads must be obtained and put into toilet and bathrooms throughout the home. Containers for liquid soap must be in place in all bathrooms and toilets including the staff room and filled with the soap. Paper towel holders must also be in situ. The store room in reception must also be tidied as there are potential health and safety risks to staff. The skill mix of the staff team must be reviewed to ensure that the appropriate skill and experience of staff are on duty in sufficient numbers to meet the needs of the residents. Staff must receive clients specific training and there must be evidence to demonstrate individual staff training is updated and they have the skills to meet resident needs. A competent, experience and qualified person must be appointed as the manager. The system for managing resident’s personal allowances must be reviewed and updated. The mandatory training for all staff must be completed and all staff must be up to date with all of this training. All staff must be involved in two fire drills per year, which are not 19/09/05 12 OP27 19 19/09/05 13 OP30 18 01/12/05 14 15 16 OP31 OP35 OP38 9 17 23 01/12/05 19/09/05 01/12/05 Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 24 linked to the weekly fire equipment test. The policies and procedures must be reviewed and fully updated. 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 Refer to Standard OP1 OP12 OP15 OP28 OP33 Good Practice Recommendations The format for the Statement of Purpose continues to be in need of further development, making it more accessible to residents. The recreational activity programme should be developed further. The system for delivering meals to residents should be reviewed to ensure all resident’s receive their meals in a timely fashion. A minimum of 50 of care staff should be trained to NVQ level 2. The quality assurance systems should be developed further and made accessible to residents/relatives and staff and clear action plans should be produced as a result of this. Staff supervision should be carried out for all care staff and completed at the required regular intervals. 6 OP36 Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Ingleby Nursing Home DS0000055360.V251013.R01.S.doc Version 5.0 Page 26 - 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. 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