Inspection on 21/05/08 for Mulberry Care Dementia Unit

This inspection was carried out on 21st May 2008.

CSCI found this care home to be providing an Adequate service.

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

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Mulberry Care Dementia Unit 155a Wokingham Road Earley Reading Berkshire RG6 1LP Lead Inspector Yvonne Souden Unannounced Inspection 21st May 2008 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 Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mulberry Care Dementia Unit Address 155a Wokingham Road Earley Reading Berkshire RG6 1LP 0779 8905346 0118 9346872 satsahluwalia@tiscali.co.uk 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) Mulberry Care Ltd Mrs Julia Claire Tavener Care Home 13 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 2. Dementia (DE). The maximum number of service users to be accommodated is 13. Date of last inspection New Service Brief Description of the Service: Mulberry Care Dementia Unit is registered to provide a service to older people who have dementia, not falling within any other category, and is adjoined to Mulberry House. Both services are individually registered with CSCI and are owned by the same provider, sharing the same address, front door, kitchen, laundry and grounds. The home is furnished and decorated to a high standard, with private rooms and en-suite facilities. At the time of this inspection a major refurbishment of Mulberry House was taking place; the garden area was inaccessible to the people who use the services’ and plans are in place to landscape the garden, and add a secure sensory garden for the people who live within the Mulberry Care Dementia Unit. The home is located within a residential area approximately two miles from Reading Town Centre. Car parking is available. Mulberry Care Dementia Unit has a Statement of Purpose and a Service Users Guide for people to view on application to the home. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The provider completed an Annual Quality Assurance Assessment (AQAA), which is a legal document provided by the commission. The AQAA was used by the provider to review their service and inform the commission of their findings. The AQAA was used as part of the evidence to inform the report. Other evidence used to inform the report includes a 9.5-hour site visit to the service by the inspector. This enabled the inspector to observe care practice and speak to people who use the service, staff and management of the home. There were no visitors to the home on the day of the inspection to volunteer their views of the service provided. Compliment letters received by the provider demonstrate that people are happy with the service provided. The Commission for Social Care Inspection (CSCI) sent surveys to people who use the service and to health and social care professionals involved in their care; surveys were not returned and therefore we are unable to include the views of the people who use the service and/or their representatives within this report. Other evidence used to inform this report was documentation viewed by the inspector at the site visit. From the evidence seen by the Inspector and comments received, the Inspector considers that the home would be able to provide a service to meet the needs of individuals of various religion, race, or culture. The home follows the organisation’s policy and guidelines to manage issues relating to equality and diversity. What the service does well: The service provides a warm and welcoming atmosphere within an environment that has furnishings and décor of a good and comfortable standard. Staff are aware of the needs of the residents and treat them with dignity and respect. Staff say and some records demonstrate that staff receive health and safety training to promote the safety and well being of the residents. Residents are provided with a nutritionally balanced diet that considers their choice and specialist dietary needs, and have recreational activities provided. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 6 The manager and provider are enthusiastic to move the service forward and are in the process of implementing systems that will monitor the service provided to ensure the service promotes residents choice, safety and wellbeing. 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. The summary of this inspection report can be made available in other formats on request. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 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 Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is available for those people who use or are considering using the service, and procedures of assessment are in place to reassure those people that the service can meet their needs, but to date this has not been full proof. EVIDENCE: The service has developed a Statement of Purpose and Service Users Guide. Information received from the service’s Annual Quality Assurance Assessment (AQAA), confirms that the service aims to further develop both documents as Mulberry Care Dementia Unit develops. The responsible individual confirmed that he would add the address and telephone number of the person named in the service users guide who would respond to compliments, concerns, or complaints. The Annual Quality Assurance Assessment (AQAA) dated 2nd March 2008 reports that 7 service users were in residency. At the time of the site visit the manager confirmed that 6 service users were in residency, and that 4 service Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 9 users from the separately registered service Mulberry House had moved to the unit in the short term whilst major refurbishment to improve the facilities within Mulberry House takes place. The manager confirmed that 3 service users return to Mulberry House in the daytime, and that 1 remains on the dementia care unit. It was established that the service user who remains on the unit was admitted to Mulberry House two weeks prior to the inspection, and to date had not lived within Mulberry House. The service user is under the age of 65, has a learning disability and diagnose of dementia and is currently under assessment. Confirmation should be sought of the service uses primary care needs to ensure appropriate placement to meet those needs and that those needs are within the category of care that the home is registered. The provider confirmed that deployment of staff from Mulberry House takes place to meet the needs of those service users who have transferred to the dementia unit albeit overnight or throughout the day, but the rota on the dementia unit did not identify extra staff used on the unit whilst service users from Mulberry House are in residence. As the two services are separate registrations the provider and manager must ensure strict admission and discharge procedures are followed from one service to another, and must ensure that all service users admitted into the dementia unit are within the category of care that the service is registered. There was evidence that the service completes and has obtained health and social care assessments of service users prior to their admission. Assessments identified primary health care needs and personal, social and health care needs. One of the assessments viewed within case tracking identified that a service user was admitted out of category. The service user’s primary care need is learning disability/older person. The manager confirmed that the service user had been admitted as an emergency from a learning disability respite service and that she thought the service user had dementia as the service user was slightly confused, but no health or social care assessment in place had detail to confirm a diagnose of dementia. A multi agency assessment/review confirmed that the service user had the capacity to make a decision in life and that the service user had decided to live independently and would therefore move back to independent living. Records of two other service users confirm that their assessed primary care need is within the category of care that the service is registered. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home works closely with Health and Social care professionals to ensure the health and personal care needs of the people who use the service is met with dignity and respect as detailed within their plan of care. EVIDENCE: Service user files viewed gave clear information on how to support and meet the individual needs of the service user and minimise identified risk. Records identified health and social care involvement to meet those needs and of regular reviews. The service communicates well with health care professionals evident from minutes of health care meetings and from health and social care assessment/reviews of the service users needs. Staff complete daily care plans that are separate but in duplicate of records kept within the main file. Records completed by staff include a tick box chart of personal care tasks delivered, daily report writing that is transferred to the main file, and a body map used to monitor and safeguard the person. The manager and provider said they would review the amount of duplication of Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 11 records to free up valuable staff time; records viewed were accurate and complete. Service users’ and their representatives are involved in regular individual meetings with the manager to discuss the service users needs and to confirm if those needs are met, but these meetings are mostly held separately, for example monthly meeting with a service user and separate monthly meeting with their next of kin or representative. It would be good practice to amalgamate those meetings as part of a monthly review of the individual service users care plan to ensure it is person centred and up to date, and has the signature of the service user and/or their representative in agreement of the plan of care in place. Incident reports are completed; staff should remember to record a reference number on the incident report and file the report within the service users file. Records of chiropody visits should be recorded within the health care section of the service user file as opposed to a separate file that details chiropody appointments attended by all service users’. The service complies with policies and procedures for the control, storage, disposal, recording and administration of medication. A new medication cabinet was observed and had a number code padlock to release the cabinet from its fixed location on administration of medication. Medication is administered by staff from a monitored dosage system as dispensed by the pharmacist, and clearly identifies the service user receiving the medication within the individual medication packs and medication records. Staff confirmed that they have had medication training via Boots Pharmacy and that only trained staff administer medication from the monitored dosage system. Medication in stock match records kept. On the day of the inspection staff were seen to treat service users’ with dignity and respect, staff knocked on service users’ doors before entering, and responded to service users’ requests for assistance in a caring and pleasant manner. Call bells are located throughout the home to enable those service users who are able to understand the system to call for assistance when required, and staff were observed to respond as the call bell was sounded. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are enabled to maintain links with family and friends, are involved in menu planning and have activity plans in place to meet their social and recreational needs. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) stated that an activity plan had been developed and rolled out. There was evidence that various forms of activities are in place, and this was observed as service users enjoyed an arts and craft session delivered by staff. Staff are receiving ‘yesterday, today and tomorrow’, dementia care training, and the manager has attended an external course on dementia care. The recreational and activty needs of the service users was observed to be met. Occupancy numbers were low at the time of the visit and dependancy levels of those service users were mostly low; the service has plans in place to ensure this outcome area remains good as numbers increase and dependancy levels differ. The AQAA confirms that the service aims to improve within the next twelve months by employing a full time activities manager to plan and organise individual and group activities and manage and train staff to provide activities at different times of the day depending on service user needs. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 13 The home has a menu plan that offers choice, and service users are asked their preference and opinion of the meals provided at their monthly review meeting. Service uses’ were observed to enjoy each other’s company as they sat around the dining table in conversation and said that they enjoyed their meal. Service users bedrooms have a memory board outside to enable them to place a picture/item that will help them to identify their room. Only one service user had chosen to use the memory board. Bedroom doors do not identify room numbers or names clearly; a small piece of paper written in pencil details the name of the service user. Clearer identification of room numbers and name of service user is recommended to enable service users to identify their rooms without undue distress. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaint procedure and responds to complaints to safeguard the people who use the service. People who use the service are protected from abuse by policies and procedures in place. EVIDENCE: The service has a complaint procedure in place and as detailed within the ‘Choice of Homes’ section within this report, the provider has undertaken to add further detail to the complaints procedure within the service users guide. The Commission has received one complaint about the service provided. The complaint was substantiated and an action plan was immediately put in place by the provider to increase staff numbers, ensure separate staff are on shift within the two adjoining services, and ensure staff that work within both services have separate recruitment records and CRB checks in respect of each service. There have been no reports of safeguarding referrals or safeguarding adult investigations. Staff say that should they witness abuse or are informed of an allegation of abuse that they would report this to the manager. The manager said that all staff has attended safeguarding adult training, most recent 6th March 2008, but records were incomplete to demonstrate training received by staff and this is discussed further within the staffing section of this report. The service has a whistle blowing policy and a copy of Berkshire’s Multi Safeguarding Adult policy and procedure. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20. 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service live in a comfortable, clean and safe environment. EVIDENCE: The service is a new purpose build building that meets the environmental standards providing en-suite facilities and assisted bathrooms. Décor and furnishings are neutral in colour and contribute to a calm, comfortable and homely environment. Some service users have personalised their rooms and all rooms were observed to be comfortably furnished, clean and bright. On completion of the refurbishment of Mulberry House the service will be provided with a new-shared laundry and kitchen, and will have access to the grounds; the service aims to provide a sensory garden. Infection control policies are in place and protective clothing was observed. No offensive odours were present on the day of the site visit and the communal areas within the home were clean. The manager confirmed that staff have received infection control training; records were not in place to fully evidence training received. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the homes recruitment practices and have their needs met by a staff team who are sufficient in numbers, and appear to have the skill and competence to meet their needs. People who use the service may be at risk, as records do not fully demonstrate that a skilled and trained staff team are in place. EVIDENCE: A staff rota was evident and recruitment practices and regular formal supervision of staff safeguard the service users. The manager and two staff members spoke of training received to meet the needs of the service users. Tick box records from 3 staff files state that they have achieved all mandatory training that includes NVQ 2 and Safeguarding adults; the records do not include training dates and signature of staff member confirming that training has taken place. Some photocopies of training certificates were seen within the files, however there were insufficient training records and certificates to demonstrate mandatory and specialist training that staff have received or are scheduled to undertake. Records demonstrate that the service has approached Skills 2 Care to complete a training analysis of staff. The provider confirmed that various training organisations have been approached to improve access to training for staff, for example Reading Borough Council Safeguarding Adults. The provider confirmed that he would forward confirmation of staff training undertaken and scheduled to the Commission. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has the experience and skill to manage the service and protect the people who live there, but risks service delivery by not following admission and assessment procedures EVIDENCE: The manager has the experience and qualification to manage the service successfully and is enthusiastic to deliver a new service that meets the health and social care needs of people who have dementia. The manager is highly thought of by the staff team, and staff say they feel supported by the manager within their training and development needs. The manager has developed, and delivers a programme of activity, and confirmed that she assists service users to appointments and trips within the community, and supports care staff in the delivery of care between 08:00 and Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 18 10:30. The manager’s working day finishes at 4 PM and is on call most weekends. It is commendable and good practise for the manger to be involved in the day-to day delivery of care, to keep in touch with best practise and monitor staff as part of the services quality assurance process. Quality assurance systems have been developed and should be implemented to monitor and improve systems in place from information received. The manager should balance management time spent on delivery of care and activities, to ensure hours spent do not affect her management responsibilities of monitoring, for example, staff training, staff numbers, assessment and review of service user needs, and quality assurance. Records demonstrate that the manager had after following assessment procedures admitted a service user who was not within the category of care that the home is registered. The manager and provider had not taken the category of registration seriously by admitting service users out of category, and agreeing to service users from the adjoining service to live on the dementia unit temporarily, without following assessment and admission procedures. The manager must ensure the assessment process looks at the primary care needs of prospective service users’ and should ensure boundaries of professionalism are maintained within the assessment of need, giving weight to health and social care professional assessments on decisions made, to ensure those needs are within the category of care that the home is registered. Records viewed demonstrate that health and safety monitoring systems are in place to protect service users. Fire alarm testing is completed weekly and water temperatures are monitored to protect service users from scalds. There is some evidence of training achieved by staff, but this should be further evidenced as discussed within the staffing section of this report. Service user group meetings and compliment slips received from service users and their relatives, confirm that the people who use the service feel valued and listened to; the manager confirmed plans to use information received within the quality assurance monitoring system that is to be implemented. Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 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 3 3 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 3 3 Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? N/A 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 The registered provider and manager must ensure that service users admitted to the service are within the category of care in which the service is registered, and must not admit service users who are not within the services registered category of care. Timescale for action 21/06/08 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 OP7 Good Practice Recommendations The manager should consider holding joint service user/representative of the service user review meetings as part of their monthly review of the service user’s care plan to ensure it is person centred and up to date, and has the signature of the service user and/or their representative in agreement of the care plan in place. The manager should ensure incident reports have a DS0000070898.V363196.R01.S.doc Version 5.2 Page 21 2 OP8 Mulberry Care Dementia Unit reference number and are filed. Records of chiropody visits should be recorded within the health care section of the service user file as opposed to a separate file that details chiropody appointments attended by all service users’. 3 OP31 The Provider and manager should consult with CSCI of the services’ Mulberry House and Mulberry Care Dementia Unit detailing provisional plans to meet the needs of the service users within each service whilst the refurbishment programme of Mulberry house is in place. The plan must consider issues that demonstrate that the service users are consulted and are given a choice about moving from one service to another to accommodate the refurbishment, and demonstrate that their primary care needs are not compromised as a result. The manager should ensure strict admission and discharge procedures are followed when service users are admitted to Mulberry Care Dementia Unit from the adjoining service Mulberry House, and should ensure she works within her professional boundaries giving weight to professional judgements within the assessment process. Quality assurance systems have been developed and should be implemented to monitor and improve systems in place from information received. Records of staff training received to date and scheduled should be maintained to demonstrate that staff have the skill to meet the needs of the people who use the service. 4 OP31 5 OP33 6 OP37 Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Mulberry Care Dementia Unit DS0000070898.V363196.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!