Inspection on 25/01/06 for Mablethorpe Hall

This inspection was carried out on 25th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Mablethorpe Hall 09/07/08

Mablethorpe Hall 24/04/07

Mablethorpe Hall 26/09/06

Mablethorpe Hall 24/04/06

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mablethorpe Hall Alford Road Mablethorpe Lincs LN12 1PX Lead Inspector Mr Doug Tunmore Unannounced Inspection 25th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mablethorpe Hall DS0000065213.V278036.R02.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. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mablethorpe Hall Address Alford Road Mablethorpe Lincs LN12 1PX 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) 01507 472240 Hamilton Community Homes Limited Care Home 24 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number disorder, excluding learning disability or of places dementia (11), Mental Disorder, excluding learning disability or dementia - over 65 years of age (13) Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories:Mental Disorder, excluding learning disability or dementia, under 65 years of age (11) MD. Mental Disorder, excluding learning disability or dementia, who are over 65 years (13) MD(E). Dementia over 65 years of age (13) DE(E). Maximum number of service users to be accommodated is 24. Pat Ingham, the manager will attend bespoke Mental Health training, which addresses clinical presentations (including alcohol & drug abuse), up to date interventions in the care of adults with mental health problems; multi disciplinary working, mental health law; managing and supervising staff within mental health settings. The training will be commenced within four months of registration dated 14/07/05, this training is to be in addition to NVQ Level IV and the registered managers award. Date of last inspection Brief Description of the Service: Mablethorpe Hall is a care home providing personal care and accommodation for 24 younger adults and older people with mental health problems. The care home is owned and operated by a company, Hamilton Community Homes Limited, whose headquarters are in Leicester. The home is located on the outskirts of the coastal town of Mablethorpe. Transport such as, taxis are required to access shops, hairdressers, pubs and the other amenities, which are in the town, over a mile away from the home. The home is set in its own grounds and is accessed over an “un-adopted road”, which also services other properties. Mablethorpe Hall has been adapted and extended to provide accommodation for service users on two floors. The home is staffed as one unit, but comprises of two separate areas, being the main house and an annex. 2. 3. 4. 5. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day, with two inspectors in attendance. At the time of the inspection the home was accommodating 20 residents. Attention was paid to an anonymous complaint received by The Commission, giving details of a number of concerns. Also past requirements were looked at, with those still relevant examined. Case tracking was employed as the main inspection tool, which involves following the experience of a sample of service users and assessing the service they receive. The General Manager and members of staff were interviewed, as well as residents. Documentation was examined and a tour of the home was undertaken. The home was purchased by the current owners on the 10/10/05 and they are currently busy updating all policies and procedures and replacing those that were not available. A number of recommendations made relate to past practices, but need to be addressed by the current providers. The General Manager, staff and residents were very open to the inspection process. What the service does well: 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 6 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 Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 7 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): The above standards were not inspected on this occasion. EVIDENCE: Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 8 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 Neither residents nor their representatives are involved in the care plans. Residents are not assessed as to their care needs before admission. Accidents to residents are not recorded appropriately. The home does not administer medication appropriately. Residents felt that they are not treated with respect. EVIDENCE: Residents care plans seen describe the health and welfare needs of residents. Care plans and risk assessments did not evidence the involvement of residents and/or their relatives and were not signed by the resident or their representative. One resident said that she was not aware she had care plans and had not signed anything. It was also found that few of the residents had assessments of their needs undertaken by the home prior to their admission. Two residents confirmed that they go to the GP on their own, in taxis. Other residents said they are escorted to the surgery. Files seen did not evidence that monthly reviews are undertaken, with the last review being the 05/07/05. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 9 The home must arrange for an annual review of all residents health and welfare needs with residents, their representatives and social services, as soon as possible. An anonymous complainant has made a number of complaints regarding this home, one of which was; there have been one or two incidents in the last two months that have not been recorded. One of these incidents was an elderly lady who had had a fall. The homes accident book was seen and found that accident forms had been completed. A residents file seen also recorded in the daily notes the accident to that resident. Any abrasions or bruises are not recorded on body maps, which forms a pictorial overview of accident over a period of time. The home has not informed the Commission of any serious incident relating to the health and general welfare of residents. A community nurse was contacted who stated that she visits the home for four residents who have a continence problem. She feels that the staff are inexperienced in working with this patient group and that communication is not very good. She also said that the home does not seem to understand her role, which results in GP visits rather than visits from herself. The medication sheets were seen and it was found that no times were on the sheets when medication should be given. One resident’s medication sheet had not been signed for the mornings medication. Two residents had continuously refused medication since the 30/12/05 and 17/12/05. No medication review has been undertaken. Painkillers from one resident’s medication prescription have gone missing on a monthly basis. A second medication checklist has been incorporated, but six tablets went missing on the 14/01/06. The inspector advised the General Manager to contact the police. The home has not informed the Commission of the theft of medication. A resident confirmed that her medication is always going missing. The above poor practice is a breach of the homes guidelines on administering and recording of medication. The pharmacist inspected the home on the 22/03/05 and recorded that records are kept up to date. At the time of the inspection, the home contacted the pharmacist and arranged for an inspection, which will take place in early February 06. Medication training was also asked for and this is to be arranged. An anonymous complainant has made a number of complaints regarding this home, one of which was; on the 10/01/06 three male members of staff were put on duty from 8.00 am to 8.00 pm. There were no female carers on the rota for that day to see to the personal needs of female residents. A female resident complained to the anonymous letter writer. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 10 The home was found not to have a policy on giving personal care to residents and care plans did not reflect how individual residents intimate care needs were to be met. The needs of female residents are not met by not having female carers on duty. One resident made very critical comments regarding the attitude of some care staff, which undermined the rights and dignity of residents. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 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 Residents feel that activities are not made available in the home. Risk assessments do not empower residents. Residents feel that staff do not help them to exercise choice. EVIDENCE: The home does not have a list of activities that residents undertake. None of the residents access voluntary work or have regular access to the wider community facilities. The homes risk assessments were seen not have been completed and did not have strategies for dealing with the risk posed by residents. Residents commented that its ‘very boring, not enough activities’. One said that she plays cards and dominoes with staff, but not with other residents. Two residents confirmed that they used to go to a day centre but that they had stopped going now. The signing in book was seen, which showed that visitors do attend the home. Two residents commented that one gets occasional visitors and the second does not get any visits from her family. The provider commented that activities are to be made available and care plans reviewed regarding accessing community facilities. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 12 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): Residents are not empowered by the homes complaints procedure. The home does not have robust adult protection procedures for the protection of residents EVIDENCE: An anonymous letter was received by the Commission relating to a number of complaints, concerning the care of residents and facilities within the home that could be a danger to residents. The complaints are listed below, as well as the outcomes and the standards in which the component parts of the complaint are listed. • A serving hatch has been put in the main kitchen and staff are concerned it is a fire risk. The Fire Safety and Rescue Officer attended the home on the 26/01/06, after receiving an anonymous letter about the serving hatch. He has confirmed to the provider that the hatch does not pose a fire hazard to the home. This will be put in writing, with a copy sent to the Commission. This complaint is not upheld. • On the 10/01/06 three male members of staff were put on duty from 8.00 am to 8.00 pm. There were no female carers on the rota for that day to see to the personal needs of female residents. A female resident complained to the anonymous letter writer. DS0000065213.V278036.R02.S.doc Version 5.1 Page 13 Mablethorpe Hall This complaint is upheld see standard 10. • Staff are concerned that the home has no leader (registered care manager). This complaint is upheld see standard 31. • There have been one or two incidents in the last two months that have not been recorded. One of these incidents was an elderly lady had a fall. The second incident was an allegation of physical abuse involving a care worker and a resident. This complaint is upheld see standard 8 and 16 & 18. The homes complaints forms and policies were not available in the home during this inspection. The provider had investigated a complaint, which in fact was an allegation of adult abuse, with the Social Services Department needing to be informed. An immediate requirement was made and a letter was sent to the owners regarding this matter. A resident commented that ‘no one listens’. The home was found not to have Lincolnshire County Councils Adult Protection Procedures. This document must be obtained for the information of the provider and care staff and for the protection of residents. A carer stated that she had undertaken adult protection training in the home, with the aid of a video and a questionnaire. She commented that ‘the training was too easy’. She also said that if abuse came to her attention she would inform the provider or the Social Services Department. She also said that new staff have not had any adult abuse training. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 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): The above standards were not inspected on this occasion. EVIDENCE: Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 15 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 Appropriate recruitment practices are in place. Staffing level meets the needs of residents. The gender mix of staff does not always meet residents’ needs. The home does not provide adequate training for care staff. The home does not have a training profile. EVIDENCE: Two personnel files seen contained CRB checks (Criminal Record Bureau), references and application forms. However, the home does not record interviews for those prospective carers who apply for posts at this home. All care workers have not been given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The home has twelve staff to provide care for those residents who live in this home. The staff rota showed that adequate staffing levels are available during the night and daytime. However, the gender mix of staff, on occasions, is not appropriate in meeting the needs of female residents in this home. Residents confirmed that three staff are on duty during the day and two at night. All residents seen said that there were enough staff on duty. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 16 The home does not have a record of training undertaken by care staff or a planned training programme for the coming year. Three care workers have NVQ (National Vocational Qualifications) level 2, with two carers (night time workers) having NVQ level 3. The home does not meet the standard for 50 of its staff trained to NVQ level 2 by 2005. However, it is recognised that steps are being taken to address this training need. None of the care workers undertake the National Training for Social Care (TOPSS) induction training. The General Manager commented that TOPSS induction training for care workers would be introduced in the near future to raise the awareness of all carers to the care needs of residents. Not all mandatory training has been made available in the home. Most of the training has been undertaken by using videos and questionnaires. The home has neither a training profile nor a training plan for the coming year. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 17 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): 31,32, 35 & 38 The home does not have a care manager. Residents do not benefit from the management ethos. Residents cannot be assured that their safety and financial interests are fully safeguarded. EVIDENCE: The home does not have a care manager and is run by senior carers who are on duty on that given day. The provider visits weekly or fortnightly depending on the support required by the home. The General Manager commented that she has advertised locally for a manager and has not been successful. Two carers commented that they get on with the General Manager and that ‘she will tell you what she thinks and is open and approachable’. Another carer stated that ‘she won’t be able to change the staffs attitude’. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 18 The homes statement of personal account was seen and the monthly income sheet. Resident’s personal allowances are kept in separate wallets and an accurate account is kept. However, monies belonging to residents are not kept in an individual account for named individual residents and is held by the owners of the home. The General Manager stated that when they took over the home residents finances was the biggest issue, with no record or invoices available and the homes ledger being inaccurate. The range of policies and procedures available to the care staff for the protection of residents and staff is mixed. Certificates were available showing that the shaft lift and hoists had been serviced. There was no evidence that fire drills, fire tests or emergency lighting had been tested. The Commission has not received Regulation 26 reports from the providers regarding the running of the home. The Commission has not received regulation 37 notifications from the providers relating to any occurrence, which adversely affects the general health and welfare of residents. Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 x x x x x x x x 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 2 2 x x 2 x x 2 Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The home must ensure that consultation with residents and relatives is undertaken and that care plans are signed to confirmed agreement on the care to be delivered. The home must ensure that residents have signed their risk assessments and are aware of the restrictions that this may impose upon them. The home must not provide accommodation to a resident unless a suitably qualified trained person has assessed the needs of the resident. The registered person must review at appropriate intervals the quality of care provided at the home. This must now be undertaken as soon as possible with social workers or health care professionals. The home must give notice to the Commission without delay of any event, which adversely affects a resident. The registered person must ensure the safe recording, DS0000065213.V278036.R02.S.doc Timescale for action 25/03/06 2 OP7 13 (4) 25/03/06 3 OP7 14(a) 25/03/06 4 OP7 24 25/03/06 5 OP8 37 25/01/06 6 OP9 13 25/03/06 Mablethorpe Hall Version 5.1 Page 21 7 OP9 37 8 OP9 13 9 OP10 12(4)(a) safekeeping and administration of medicines in the home (Timescale of 31/10/05 not met). The home must give notice to the Commission and or the police without delay of any event, which adversely affects a resident in this instance a residents medication regularly going missing. The registered person must review the medication of residents especially those who have refused their medication over a period of time. The home must ensure that a policy/guidelines on giving personal care to residents is made available to care workers and takes into account gender issues and is part of their induction. The registered person must consult with residents about a programme of activities for their recreation. The registered person must consult with residents about their interests and make arrangements to enable them to engage in local, social and community activities. The home must mindful in the manner that residents are addressed so as to maintain their dignity. The home must have the complaints procedure and complaints forms and previous complaints investigated available on the premises. The home must ensure that all residents have a written copy of the complaints procedure. The home must obtain those documents and guidelines DS0000065213.V278036.R02.S.doc 25/01/06 25/03/06 25/03/06 10 OP12 16 (n) 25/03/06 11 OP13 16(m) 25/03/06 12 OP10 12(4)(a) 25/03/06 13 OP16 22 25/03/06 14 15 OP16 OP18 22 13(6) 25/03/06 25/03/06 Page 22 Mablethorpe Hall Version 5.1 16 OP18 13(6) 17 OP18 37(g) 18 OP27 18 19 OP28 18(1) 20 OP29 19 required for the protection of residents from abuse. The home must ensure that all workers employed at this home undertake adult protection training. The home must inform those agencies charged with the protection of vulnerable adults of any allegation of misconduct by any person who works at the care home. The home must ensure that suitably qualified, competent and experienced persons are working at the care home and the rota reflects the needs of residents. The home must have a minimum ratio of 50 trained staff members to NVQ level two excluding the registered manager. The registered person must ensure that there are robust staff recruitment procedures. (Timescale of 31/10/05 not met). This inspection found that interview notes are not made and kept of those care staff applying for a post at this home to help ensure the safety of residents. The home must ensure that new staff undertakes appropriate in house induction training so that residents are well cared for and safe. The home must record all training and planned training to be undertaken by staff. The home must keep and a record of training undertaken and planned future training. The registered person must ensure that all staff undertake mandatory training. DS0000065213.V278036.R02.S.doc 25/04/06 15/01/06 25/03/06 25/08/06 25/03/06 21 OP30 18(c)(i) 25/03/06 22 23 24 OP30 OP30 OP30 18(c )(i) 18(c) 18(c )(i) 25/03/06 25/03/06 25/03/06 Mablethorpe Hall Version 5.1 Page 23 25 OP31 18 26 OP31 9 27 OP31 8 28 OP35 20(a) 29 OP38 23(4) 30 OP38 26 31 OP38 37 The registered person is to source mental health training to include alcohol dependence, the registered manager and members of staff are to attend. This requirement is outstanding from the last two inspections (Timescale of 31/10/05 not met). The manager is to undertake specialist mental health training. Requirement outstanding since the last two inspections, as a condition of the manager’s registration. (Timescale of 31/12/05 not met). It is acknowledged that the home does not have a manager at the present time. The home must appoint an individual to manage the home where there is no registered manager in respect of the home. The registered person shall not pay money belong to any resident into a bank account unless- the account is in the name of that individual resident. The home must consult with the fire authority for keeping records relating to the safety of residents and the prevention of a fire. The registered person must visit the home at least once a month and interview residents and persons working at the home as appears necessary in order to form an opinion of the standard of care provided in the home. The provider must supply a written report to the Commission of the findings of the unannounced visit. The registered person must give notice to the Commission without delay of the occurrence of any event in the care home which adversely affects the well DS0000065213.V278036.R02.S.doc 25/06/06 25/06/06 25/04/06 25/03/06 25/03/06 25/03/06 25/03/06 Mablethorpe Hall Version 5.1 Page 24 being of any resident. 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 Refer to Standard OP8 10 Good Practice Recommendations The home should introduce body maps for the recording of all accidents resulting in bruising or abrasions. The home would benefit from a designated phone line for service users, ensuring them of their privacy whilst making telephone calls; whilst ensuring that the home has telephone access to emergency services at all times. These recommendations are outstanding from the last three inspections. The provider stated that this is now in hand. The home should furnish all staff with the General Social Care Councils Conduct of Practice for their information. The home would benefit from the development of “Supportive Observation” and “Self-Harm, Suicide prevention” policies and procedures in line with national guidance. (This recommendation was made at the unannounced inspection dated 21/09/05). 3 4 OP30 OP38 Mablethorpe Hall DS0000065213.V278036.R02.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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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