Inspection on 07/06/05 for Nada Nursing Home

This inspection was carried out on 7th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Nada Nursing Home 05/04/07

Nada Nursing Home 04/09/06

Nada Nursing Home 26/06/06

Nada Nursing Home 19/01/06

Nada Nursing Home 27/10/04

Nada Nursing Home 29/04/04

Nada Nursing Home 09/02/04

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

CARE HOMES FOR OLDER PEOPLE Nada Nursing Home 451 Cheetham Hill Road Cheetham Hill Manchester M8 9PA Lead Inspector Gary Largent Unannounced 07 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Nada Nursding Home Address 451 Cheetham Hill Road Cheetham Hill Manchester M8 9PA 0161 720 7728 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Pierre Grenade Mr Pierre Grenade Care home with Nursing (N) 28 Category(ies) of Dementia -over 65 years of age (DE(E)) registration, with number of places Mental disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 Registered for a maximum of 28 service users of either sex over pensionable age suffering from either mental disorder or dementia. 2 The maximum number of service users requiring nursing care shall be 17 and the maximum number of service users requiring personal care only shall be 11. 3 Registration is subject to compliance with the minimum staffing levels indicated in the Notice served in accordance with Section (25) 3 of the Registered Homes Act 1984 issued on 6th March 2002. Date of last inspection 27 October 2004 Brief Description of the Service: The Nada nursing and residential home provides accommodation with nursing and personal care for a maximum of 28 older people. The care home is able to offer accommodation to 17 older people assessed as requiring nursing care and 11 service users assessed as requiring personal care only. The home is owned and operated by Mr Pierre Grenade, who is both the registered person and the manager. The home is situated in the Cheetham Hill area of North Manchester close to local shops, Manchester City centre, social, cultural and recreational amenities. The home was first registered with the National Care Standards Commission, now CSCI, on 30th July 2002 and it consists of a converted large detached house with a large, modern extension within its own small grounds. The home is able to offer off-the-road parking for approximately five vehicles in addition to the home’s mini-bus. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors did the unannounced inspection on 7 June 2005 between 8am and 5pm. Twelve residents were spoken with during the inspection in addition to 7 staff members and the home’s management team. The residents were positive in their comments regarding the home, the standards of care and the accommodation provided. The inspection included a tour of the home where the living conditions were inspected. Care, medicine, accident, duty, fire, complaint and other records were inspected in addition to staff personnel files. During the inspection only a selection of key standards were assessed. Therefore, in order to gain a full picture of how the home meets the needs of residents this report should be read with the previous and any future reports. What the service does well: The residents said that they like the food served at the home. The home offered menu choices at each mealtime. They spoke well about the home, the staff, the care and support provided. The staff members were seen to be respond to residents’ needs. The staff appeared to work with the residents in a caring and considerate manner and to have an awareness of the residents’ needs, their choices and preferences, although these did not appear to be recorded. The residents, when asked, stated that they enjoyed living at the home. The residents spoken with knew how to make a complaint and were aware of the complaint procedure. The residents stated that the staff were friendly, and helpful. The staffing levels at the home appeared to be adequate to assist and support the residents. 50 of the home’s care staff had successfully completed the National Vocational Qualifications. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 6 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. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 and 5 The information provided to prospective residents is inaccurate and preadmission needs assessment practices are poor. These shortfalls had the potential to place residents at risk. EVIDENCE: The revised Statement of Purpose and Residents’ Guide contained a number of inaccuracies. The information provided did not enable prospective residents to make an informed choice about possible admission to the home. The requirement made at the last inspection in respect of this had not been met and has been reiterated. Thorough pre-admission assessments had not been conducted thereby limiting the home’s ability to meet the residents’ needs. The assessments by the social worker and National Health Service nurse were available. The manager did not routinely confirm the home’s ability to meet the prospective residents’ needs. The home offered specialist care for people with mental health issues and dementia. A Registered Mental Nurse (RMN) was in charge of the home at all times to help meet the residents’ identified needs. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 9 At the timeof the inspection the home had admitted one person for a six-week trial period who was below the minimum age agreed by the home as a condition of its registration. This was discussed at some length with the provider. He was advised of the need to make an application to the Commission for Social Care Inspection to vary the home’s conditions of registration in relation to this particular resident. The home did not offer intermediate care services. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, and 9 There have been marked improvements in these areas but further improvement is needed. Plans of care must be based upon needs assessment to ensure their relevance. EVIDENCE: The plans of care were not created from comprehensive pre-admission assessments although the assessments by the National Health Service nurse and care manager were referenced. The sample of care plans inspected contained evidence of the residents’ involvement in their completion and monthly review. Risk assessments, including a history of falls, were completed and integrated into the plans of care that were specifically referenced within the daily statements of health. The residents’ records contained evidence of the involvement by other healthcare professionals e.g. community opticians were visiting the home at the time of the inspection. All residents were registered with an identified local General Practitioners. None of the residents had pressure sores and appropriate pressure sore risk assessments had been conducted. A number of residents were dependent upon the use of wheelchairs many of which were not fitted with footrests. A review of the relevant care packages demonstrated that the removal of the footrests was not supported by risk assessments. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 11 The home’s medication administration procedure appeared safe at the time of the inspection. The policy, including the updated revisions, contained insufficient detail in relation to medication ordering, recording, receipt and disposal and storage etc. The policy must be reviewed and, upon completion, provided to the Commission for Social Care Inspection. Details should contain advice for staff members of when and why to administer “as required” medication. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 15 The residents were able to contribute to the management and conduct of the home. Meals appeared to be varied, nutritious, healthy and balanced. EVIDENCE: Residents were seen to be able to move about the home freely as well as to leave and re-enter at will. Many of the residents took advantage of the good weather to spend extended periods within the home’s garden. The home had a designated smoking area. The home had arranged for spiritual leaders to visit and for residents to attend their chosen places of worship. Little information was recorded regarding the residents’ hobbies or interests e.g. a new resident at the home advised the inspector of his desire for a named daily newspaper. The manager was unaware of this and it had not been recorded within the residents’ care package. Minutes of a recent residents’ meeting were available. The home’s menus indicated that a varied and wholesome diet was available and that alternative meals were available at any of the mealtimes. The home’s stock of food supplies had improved since the last inspection. An experienced Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 13 chef had recently been appointed to the home. The chef had provided an appetising, balanced and nutritious diet. Refrigerator and freezer temperatures in addition to core cooking temperatures had not been recorded since February 2005. Kitchen cleaning records were unavailable although the kitchen was extremely clean and tidy. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 The home’s recording of complaints remained poor and needed to be improved. The home’s financial management systems protected residentsfrom abuse. EVIDENCE: The complaint procedure contained a 28-day response timeframe and met the requirements of the Care Standards Act 2000. The Commission had received 1 complaint about the home during the 12-month period preceding the inspection. The complaint had resulted in all residents undergoing a review by the appropriate Local Authority review team. The reviews resulted in two issues being considered under the vulnerable adults procedures. These issues had been upheld and the provider had agreed to pay restitution to the residents involved. The home’s recording methods in relation to complaint reporting was poor. The outcomes of complaints and the action taken by the home to address any shortfalls were not clearly recorded and should be revised. The Manchester multi-agency Protection of Vulnerable Adults policies, procedures and protocols were available within the home. The home had employed an administrator who has developed individual financial files for all residents. Some residents had bank accounts others shared an account but individual balance statements were available. Receipts were available for all transactions involving the residents’ monies. The residents signed a receipt for their personal allowances. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22 and 26 The home is accessible and suitable for its stated purpose. Some of the furniture and flat linen etc needs to be replaced. EVIDENCE: The home was accessible by a ramp and a passenger lift offered access to all levels of the home. The small grounds were maintained and in use by the residents at the time of the inspection. The handyman maintained a workbook, which acted as a record of routine maintenance. There were records of the participation of staff members in fire awareness training. A fire drill was due at the time of the inspection. Fire precaution and emergency call systems were fitted to each room. Combustible materials were stored near the fire exit at the side of the home. This was brought to the providers attention. The issue was dealt with during the inspection and has not resulted in requirements being issued. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 16 The home had a main lounge area with two smaller lounge areas, one being the designated smoking lounge. The ventilation within the smoking lounge was adequate. The chairs within the smoke lounge area identified at the two previous inspections as being badly worn and requiring recovering or replacement were still present. Wheelchair users were able to move around the home freely. Ramps and widened doorways were provided to enable the passage of wheelchairs and portable hoists. Appropriate aids and adaptations appeared to be fitted to the home although no risk assessment was available for inspection. The provider stated that he had provided some items of soft furnishings and other items e.g. bed linen, towels, face cloths etc to meet the needs of the residents. The amounts provided were inadequate and more should be provided as required. The home’s laundry was situated on the ground floor “service” corridor. Soiled linen did not come into contact with food storage, preparation, cooking, serving or dining areas. Literature was available in regarding the Control of Substances Hazardous to Health (COSHH). The home had policies relevant to infection control. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The number and deployment of staff was sufficient to meet the residents’ needs. Although the home’s recruitment practices placed vulnerable residents at potential risk of harm. EVIDENCE: The home accommodated 11 residents assessed as requiring nursing care, although one of these was in hospital at the time of the inspection and 10 residents assessed as requiring personal care. The home’s duty records indicated that sufficient staff were on duty at all times to meet the needs of the residents accommodated. The home had appointed a chef. 7 of the home’s 14 care staff had achieved the NVQ level II award. 1 staff member had achieved level III and a further staff member was undertaking level III. The home’s recruitment process was not compliant with those measures intended to provide protection to vulnerable adults. The provider had distributed copies of the code of conduct and practice published by the General Social Care Council (GSCC). The information required by Schedule 2 of the Care Homes Regulations 2001 was not consistently available within the home. The uptake of Criminal Record Bureau (CRB) disclosures had not kept pace with recent changes. The POVA First checks, available since 26 July 2004, had not been conducted. This was the subject of a previous Immediate Requirement Notice however the timescale to address this shortfall was not due to expire until 22 June 2005. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 18 There was no evidence to support that new employees received any form of induction process geared toward enabling them to meet the changing needs of the residents and the home. There was no evidence that the home had implemented induction or foundation training to NTO specification, to be provided to staff within six-weeks and six months respectively of their appointment. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 36 and 37 Recent changes have resulted in the residents’ financial interests being more safeguarded than previously. Staff are not appropriately supervised. EVIDENCE: The provider was also the home’s manager. The manager had many years experience as a Registered Mental Nurse (RMN) and in providing and managing care services for older people. The manager had not enrolled on a course leading to the Registered Managers’ Award. The home’s senior staff appeared to be familiar with the diseases and conditions associated with the residents group. The manager provided the inspectors with the record of a recent staff meeting. The provider/manager had retained evidence that he had provided all of the home’s employees with copies of the code of conduct and practice issued by Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 20 the General Social Care Council (GSCC). The home had an equal opportunities statement. No evidence was available regarding the use of a quality assurance or selfaudit tool. The home did not use a system of residents satisfaction questionnaires in obtaining feedback regarding service provision. There was no evidence available to demonstrate that community stakeholders were encouraged to express their views regarding the home’s ability to meet its stated goals. The provider had compiled a business or financial plan, which was available for inspection. The home’s insurance certificate was displayed in the home’s entrance area. The insurance schedule confirmed that at least £5million cover was available. The insurance certificate was valid at the time of the inspection. The home’s new administrator had implemented a number of financial procedures aimed at protecting the residents’ financial interests. The residents’ financial records were inspected and all of the residents appeared to receive their personal allowance on a weekly basis. The home’s financial records supported the residents’ receipt of their personal allowances. Those residents who spoke with the inspectors confirmed their weekly receipt of their personal allowance. The residents signed a balance sheet to verify their receipt of their money. The residents were largely responsible for their own, personal, financial management. All residents received direct payments. Two members of the Local Authority review team were at the home during the inspection and an application has been made to patients, services to represent each of the residents’ financial interests. There was no record of any staff supervision, which must cover all aspects of practice, the philosophy of care in the home and career development needs. Volunteers were not used at the home. The records maintained within the home were largely compliant with Schedule 3 of the Care Homes Regulations 2001 in relation to the residents and these were retained securely within the home. The records in relation to staff members were inadequate, e.g.CRB disclosures and employment references etc. The home had developed a policy relating to the residents having access to their records. Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 2 x 2 x 2 x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 2 2 3 3 2 2 x Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 22 Yes 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 OP1 Regulation 4(1) (2) 5(1) (2) (3) Requirement The provider/manager must ensure the presence and availability of a written Statement of Purpose and Service User Guide, which must be distributed in keeping with the Care Homes Regulations 2001. Previous timescale 8.12.2004 not met. The provider/manager must not provide accommodation to a resident unless a suitably qualified or trained person has appropriately assessed their needs. Any assessment must be kept under review and revised appropriately. Previous timescale of 8.12.2004 not met. The provider/manager must not admit any resident to the home without first ensuring that the home is fully able to meet that persons assessed needs. In addition, confirmation must be given to the prospective resident, in writing, that the home is able to meet their assessed needs. Previous timescale of 8.12.2004 not met. Timescale for action 7/8/05 2. OP3 14(1) (2) 7/8/05 3. OP4 12, 14 7/8/05 Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 23 4. OP8 12, 13 5. OP9 13(2) 6. OP12 16(2) (m) (n) 7. OP15 13(3) (4)(c) 16(2) (g) (j) 16, 23 8. OP20 9. OP22 23(2) The provider/manager must ensure that appropriate risk assessments are carried out in relation to the use of wheelchair footrests etc. The provider/manager must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Previous timescale of 8.12.2005 not met. The provider/manager must record the residents social interests and encourage their participation in such activities. Previous timescale of 8.12.2004 not met. The provider/manager must take precaution against unnecessary risks to health or safety of the residents and maintain satisfactory records relating to the kitchen. The provider/manager must provide furnishings in the smoking lounge that are fit for their intended purpose. Previous timescale of 8.12.2004 not met. A risk assessment must be conducted in respect of the aids, adaptations and equipment required to more fully meet the residents’ assessed needs. Previous timescale of 8.12.2004 not met. The provider must ensure that all necessary recruitment checks are undertaken on prospective staff prior to their employment at the home as specified in Schedule 2 of the Care Homes Regulations 2001. Previous timescale of 8.12.2004 not met. 7/8/05 7/8/05 7/8/05 7/8/05 7/8/05 7/8/05 10. 11. OP29 19, Schedule 2, CSA Section 89 22/6/05 Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 24 12. OP30 12, 13 and 18 13. OP30 12, 13 and 18 14. OP33 24 The provider/manager must 7/8/05 ensure that the staff are fully able, at all times, to meet the residents’ assessed and changing needs. Previous timescale of 8.12.2004 not met. The provider/manager must 7/8/05 ensure that all staff undertake appropriate induction training within 6 weeks and 6 months respectively of their employment.This requirement was made at the previous inspection and the timeframe of 8th December 2004 was unmet. (a) The provider/manager must 7/8/05 ensure the establishment and maintenance of a system for reviewing and improving the quality of care at the home. (b)The provider/manager must publish the results of any resident surveys. Previous timescale of 31.1.2005 not met. 15. OP36 18 The provider/manager must ensure that care staff receive appropriate supervision at least six times per annum. The supervision must cover all aspects of practice, the philosophy of care in the home and career development needs. The provider/manager must ensure that all records held in the home meet the requirements of Schedules 3 & 4 of the Regulations. 7/8/05 16. OP37 17 7/8/05 Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations Residents should be consulted about their social and leisure interests. This recorded consultation should contribute to the development of the homes activity programme. The home’s recording and information storage methods in relation to complaint recording should be revised to comply with the Data Protection Act 1998. The manager should embark on a course of study leading to the registered managers award by the end of 2005. The policies and procedures contained within the homes quality management guide should be implemented until they are replaced with more appropriate documents. 2. 3. 4. 5. OP16 OP31 OP32 Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 9th Floor, Oakland House Talbot Road Manchester M16 0PQ 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 Nada Nursing Home F55 F05 s21566 Nada V231447 D070605 Stage 4.doc Version 1.30 Page 27 - 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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