CARE HOMES FOR OLDER PEOPLE
Newgrove House Station Road New Waltham Grimsby DN36 4RZ Lead Inspector
Bev Hill Unannounced 19 August 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. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Newgrove House Address Station Road, New Waltham, Grimsby, DN36 4RZ 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) 01472 822176 Dryband One Ltd Mrs Laxmi Autar Kaur Khurana CRH 41 DE(E) 10 Category(ies) of OP 41 registration, with number of places Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: The home is able to accept one person under the age of 65 years Ref V12749 until they reach age 65 years or terminate their contract. Date of last inspection 7.12.04 Brief Description of the Service: Newgrove House is situated in the village of New Waltham, four miles from Grimsby. It has large well-maintained grounds with mature trees and shrubs and ample car parking for visitors. The home is on a bus route to Grimsby and Cleethorpes. The home provides accommodation and care for up to forty-one people over the age of sixty-five, including a maximum of ten people with dementia. There are thirty-seven single rooms and two double rooms based on two floors that are serviced by a passenger lift and stair access. Thirty-two of the bedrooms have en-suite facilities. There are also an adequate supply of bathrooms and toilets throughout the home. All rooms have telephone points and a television provided. The home has a ground floor lounge with a large screen television and a dining room set out with individual tables. There is a further ground floor lounge, separated into two areas. This is usually used for family gatherings when privacy is required or for staff training purposes.There is a quiet room on each of the floors. The quiet room on the ground floor has a small conservatory leading from it overlooking the rear garden. The environment is homely, very clean and well presented. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The Inspector spoke to the manager and five care staff who were on duty at the time of the inspection. Throughout the day the Inspector spoke to nine people who lived at Newgrove House and two relatives. The inspector looked at a range of paperwork in relation to staff rotas, care plans, accidents, recruitment records, complaints, risk assessments, menus and policies and procedures. The Inspector also checked that people who lived in the home had the opportunity to suggest changes and were listened to. The Inspector completed a partial tour of the building and checked that all the things that needed to be done from the last inspection had been done. What the service does well:
People who lived at the home said that the staff members were ‘excellent’, ‘very kind to us’, ‘very good girls’ and will ‘help you in any way they can’, they respected their privacy and made their relatives feel welcomed. There were enough staff members on duty at any one time and people said that they answered call bells quickly. One person said he enjoyed a joke with the staff and they were friendly. Relatives stated that there was always a staff member in the main lounge with the most vulnerable people. They were kept informed of important issues, none had any complaints and they were satisfied with the care received. The care that people required was written down in care plans. The home provided a pleasant environment. It was clean and tidy and had a welcoming, homely feel. It was carpeted and decorated to a good standard. There were areas throughout the home where people could sit quietly, for example a conservatory on the ground floor and a quiet lounge on the upper floor. The home had two further lounges in which to congregate for activities. People who lived there mentioned they liked the views of the surrounding countryside. People spoken to stated that the meals were very good and there was plenty to eat and drink. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 6 Two people spoken to commented on the fast laundry service although others commented that sometimes clothes get mixed up but they are usually sorted out. What has improved since the last inspection? What they could do better:
The care plans sometimes had vague directions for staff, for example like taking the person to the toilet at regular intervals. This needed to be much clearer if staff were to try and make sure people got to the toilet before they were incontinent. The daily records that staff made about the care they provided had improved a little but there was still evidence of only one entry a day. The records must give a comprehensive picture of care provided so that their care and progress can be tracked.
Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 7 The home needed to broaden out risk assessments to look at other areas of risk, for example for people who choose to smoke, for those who may wander and for those who need protective bedrails etc. The manager had started to check the accidents that happened in the home to distinguish between trips, falls, slips etc, which was a good start, however these could be written down more comprehensively so that staff can see at a glance how many accidents a particular person is having and look at ways to change things to prevent them. The home used a form to look at the eating and nutritional needs of people who lived at the home. This was a good start but the staff must make sure that any problems picked up are reported to professionals so they can be dealt with. One person had their antibiotic medication given to them at 2am because the instructions said six hourly. Unless the GP gives strict instructions about times of medication these must be given during the waking day so people get a good nights rest. The Inspector noted that some people chose not to go to the dining room for their cup of tea mid-morning and they were not offered one in their chair in the lounge. This meant that some people might not receive all the fluids they should have throughout the day. People must be given the choice as to where they want their cup of tea and this must be respected. The policy for managing people when they were distressed still needed to be updated to include how staff managed risks and obtained support from professionals. Some staff had not received any training in how to care for people with dementia. This was important as the home had a number of people with dementia who lived there and staff needed to be able to care for them properly. Some people spoken to said the manager told the staff off in front of them when they had done something wrong. This could cause upset for the people who lived there and was not good for the staff, as this should be done in private. All staff received supervision in the form of one-to-one chats with the manager but this needed to include lots of other things such as how staff are coping with their job, what skills they might need to improve, what they are doing well, how they write things down in daily records and any issues that arise from their care of people who live in the home. Supervision was important to make sure staff were competent to provide all the care people needed. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 8 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. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 9 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 Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Service users had their needs assessed prior to admission to ensure that the home could meet their needs. EVIDENCE: The manager completed in-house assessments and there was evidence that assessments completed by Care Management were obtained by the home prior to admission. The assessments were important as they provided vital information for the care planning stage. The homes assessment documentation covered all the required points highlighted in the standard. The manager confirmed that they visited service users in hospital, other residential homes or their own home prior to admission to gather information from the service user, family and other professionals. The manager formally wrote to service users or their representatives following assessment stating the homes capacity to meet needs. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 11 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 and 8 Service users health and personal care needs were expressed in individualised care plans with tasks for staff identified. However some service users were put at risk by the lack of comprehensive risk assessments and daily recording. EVIDENCE: Four care files were examined. The care plans formulated were pre-printed sheets for each identified need and then individualised for each service user. There was evidence that staff had included needs identified at the assessment stage. Generally the care plans were comprehensive and it was clear a lot of effort had gone into their initial formulation. If service users wore glasses there was even a plan of care to ensure these were worn and cleaned. Care plans had been updated and were evaluated monthly. One area of care planning that was discussed with the manager for future application was the task for staff when a service user was in need of ‘regular toileting’. Care plans must be clear about what this means and how it is to be monitored. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 12 There was some evidence that service users or their representatives signed agreement to the care plans. The date and signature of the person individualising the pre-printed care plan was in evidence. There were no service users with any pressure sores although some had preventative measures in place. There was use of risk identification tools for nutrition, skills and moving and handling needs. There was evidence of risk assessments for those service users at risk of falls. However it was noted that other areas of risk were not addressed, for example, smoking, bedrails, alcohol use and behaviour that could pose a risk i.e. wandering in other peoples bedrooms. All areas of risk must be identified and plans made to reduce the risk to protect service users from harm. Weights were recorded monthly. However in one case it was noted that a service user had lost six pounds in a month but there was no record of follow through to seeking advice from professionals. The home needs to be proactive in seeking speedy advice from professionals to ensure service users are not put at risk. Daily recording of the care people received did not always follow through issues to the next shift and it was not always clear exactly what care had been provided. This meant that there was not always a clear picture of the service users progress and care needs could be missed. Medication will be assessed at the next inspection, however requirements made at the last inspection had been met. One issue noted and discussed with the manager was the administration of antibiotic medication at strictly six hourly intervals. In effect this meant that the service user was administered the medication at 2am. Unless there are strict instructions from the GP regarding medication throughout the night the doses should be administered throughout the waking day to ensure the service user receives a restful nights sleep. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 13 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 and 14 Service users benefited from an activity programme and were able to make choices about aspects of their lives. This would be further enhanced by greater choice regarding where to have their refreshments. EVIDENCE: The home had an activity programme on display. Service users spoken to stated that there was a range of activities on offer but some only liked to join in occasionally. They listed bingo, ball games, floor snakes and ladders, music, videos, entertainers, quizzes and walks in the garden. The home recently had a garden party for service users, relatives and friends. The Inspector witnessed a game of floor snakes and ladders and several more vulnerable service users joined in assisted by a staff member. They benefited from the exercise involved in throwing a large dice from their chair and were stimulated to varying degrees. On the whole service users spoken to felt they were able to make choices about aspects of their lives. For example people felt able to spend time in their bedrooms if they chose to and mix with others during organised activities. They were able to furnish and personalise bedrooms and the Inspector saw this to varying degrees. People could choose where to have their meals, what clothes they wanted to wear and the times they chose to retire to bed and get up in the morning. Some people had installed their own telephones and there
Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 14 were lockable facilities for people to manage their own finances. The home had two main lounges and a conservatory attached to a small dining room and a further quiet room upstairs. They were able to entertain their relatives at anytime in any of the communal areas or in their bedrooms if they preferred privacy. One person spoken to continued to remain as independent as possible with discreet observation from staff. They were able to make choices about visits to the local village and made appropriate safety arrangements with staff. Some service users, staff and relatives spoken to stated that service users were unable to have their cup of tea mid morning and late afternoon in the main lounge and were asked to go to the dining room instead. The Inspector witnessed some people decline to go to the dining room as they felt it was too far but they were not offered refreshments in the lounge. This could mean that service users would not receive an appropriate amount of fluids throughout the day. Discussions with the manager and staff revealed that they thought the exercise to the dining room would be beneficial for the service users and for some this would be the case. However if service users decide not to go and choose to remain in the lounge their choice must be respected and refreshments offered. Appropriate tables must be provided to ensure the safe provision of drinks. An immediate requirement notice was issued regarding the preservation of choice and provision of tables. One person spoken to stated they preferred to have their clothes on hangers so they can be reached more easily but sometimes staff put them on shelves just out of her reach. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 15 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 and 18 The home provided an atmosphere whereby people felt able to make complaints and felt confident they would be resolved. EVIDENCE: The homes complaint procedure was clear and displayed in the entrance. It had appropriate timescales for resolution and included contact details of other agencies. The home had a complaint form, which included aspects of the complaint and what action was taken to resolve the issue. The home also had a suggestions/niggles book for people to complete if they did not wish to formalise a complaint. Service users spoken to felt able to make any complaints they may have either to the manager, staff members or their families. There were no outstanding complaints on the day of inspection. Since the last inspection the proprietor had reviewed the adult protection policy and procedure. All three homes now had the same procedure, which was in line with the local authority policy and procedure regarding referral and investigation. Training for staff in the protection of vulnerable adults from abuse was part of the homes training plan and staff members spoken to were able to tell the inspector what they would do if they witnessed any form of abuse. The manager was aware of referral procedures. The policy regarding restraint and challenging behaviour was still in need of updating to include guidelines on behaviour management, risk assessments and referral to professionals for support.
Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 16 Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 17 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, 24 and 26 Newgrove House provided a well-maintained, clean and tidy environment for service users, who were given the opportunity to personalise their bedrooms. EVIDENCE: There had been little change in the environment since the last inspection and Newgrove House continued to provide a homely environment with furniture and décor of a good standard. The home was well maintained inside and out and complied with fire and environmental heath requirements. The home employed a maintenance worker responsible for day-to-day repairs and they ensured that any reported issues were attended to straight away. Service users spoken to were happy with the home and their bedrooms. There were two main communal lounges and a dining room and two further quiet seating areas on each floor. People spoken to liked the opportunity of spending time in their own bedrooms. The bedrooms examined had been personalised to varying degrees. People confirmed they could bring in their own possessions and they had a lockable facility to secure items. Pre-admission documentation had a form to complete regarding whether a privacy bedroom door lock was
Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 18 desired. People would then be provided with their own key unless a risk assessment detailed otherwise. The home was very clean and tidy and free from any malodours. Service users and relatives spoken to commented that the domestic staff worked hard to keep the home looking so well. Cleaning regimes were in place signed by the staff on completion. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 19 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, 29 and 30 The home provided sufficient numbers of staff on each shift to meet the care needs of service users and its recruitment practices were sufficiently robust to safeguard service users living at the home. Service users were at risk of inadequate care as not all staff had received training in how to support people with dementia. EVIDENCE: Staff rotas were examined and showed that there were five care staff on duty throughout the day and three staff at night. The manager was supernumerary, although did fill gaps in care provision due to sickness and holidays. There appeared to be two catering staff and two domestics during the morning and one catering staff in the afternoon. Also employed was a maintenance person for day-to-day repairs to the home. The rotas reflected who was on duty and in what capacity. There had been some turnover of staff since the last inspection but this had appeared to have slowed down and a core group remained. Service users and relatives spoken to were very complimentary about the staff. One person said it was difficult to understand some of the carers, as they were from overseas but all stated they were kind and caring. Recruitment records were examined of three new staff and found to comply with regulation 19 in respect of application forms, two references, proof of identity and criminal record bureau checks.
Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 20 Standard 30 will be assessed in more detail at the next inspection. The Inspector was aware of the homes training plan that included mandatory training, however during discussions with staff it became evident that some did not have a clear understanding of the needs of people with dementia. This was particularly important because the home was registered to care for up to ten people with dementia. All care staff must be provided with training in this area and the manager must audit which staff have not yet received training and put in place an action plan to address the issue. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 36 and 38 The service users benefited from a safe and well-maintained environment. This would be enhanced by effective staff supervision and a review of disciplinary methods. EVIDENCE: Via discussions with service users, relatives and staff it was noted that the manager liked to ensure that services were well provided for the service users and she had clear ideas on how staff members should perform their role and tasks. Via discussion with the manager this was confirmed and methods of staff discipline within the home were explored. Some service users and staff members had overheard raised voices during this process and although it was acknowledged that at times discipline was required as and when the infringement took place, it was suggested that the manager used her office or quiet area to discuss calmly the areas of concern with particular staff members to protect confidentiality and prevent any upset to service users. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 22 The majority of staff spoken to stated that the manager was supportive and would deal with problems. Staff supervision records were examined. The manager supervised all staff within the home, which was an enormous task give the size of the staff team. It was suggested that domestic and catering staff be supervised on a day-today basis and only care staff receive the formal, documented supervision of six sessions per year, which would meet requirements. It was also suggested that senior care staff be developed to enable them to supervise care staff in their roles. This would relieve some of the pressure on the manager. As would be expected the quantity of supervision sessions undertaken had an affect on the quality of them. Via discussions with staff and examination of records it was noted that the supervision session tended mainly to be a oneway process. The manager collated information in how she saw the staff member had performed since the last session and this was read out to them. They signed the form. To be meaningful the supervision session needed to explore how the staff member was progressing with their role and tasks, the difficulty they may experience with their key worker role, any service user issues, staff dynamics, their recording abilities, training needs and developmental opportunities. It’s a time to pass on information and to receive it, to give positive feedback and offer ideas for improvement in skills, to check care files and that appropriate documentation is in place. The manager must ensure that effective formal supervision of staff takes place. Not to do so could place service users at risk of inadequate care. The manager who is also the proprietor was proactive in ensuring the health and safety of service users who lived at the home and staff who work there. Policies and procedures were in place, equipment was serviced regularly and the home was well maintained inside and out. The fire risk assessment had been updated and staff participated in fire drills. Fire equipment checks were made. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 23 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 2 15 x
COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 2 x x x 2 x 3 Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 24 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 18 Regulation 12(1)(a) Requirement The registered person must ensure that policies and procedures for restraint and challenging behaviour includes guideleines on behaviour management plans, risk assessments and referrals for professional support (previous timescale of 31.3.05 not met) The registered person must ensure that all activities assessed to be of a risk to service users are identified with clear documented steps to minimise the risk. The registered person must ensure that daily records are clear and comprehensive about the care provided and follow throuth issues to the next shift. The registered person must ensure prompt referral to professianal advice as required and unless instructed by a GP medication is to be administered during waking hours. The registered person must ensure that service users choice about where to take refreshments is respected and tables provided for safety. Timescale for action 31st Oct 2005 2. 8 13(4) and 14 31st Oct 2005 3. 8 12(1)(a) 4. 8 13(1)(b) From date of inspection 19th Aug 2005 From date of inspection 19th Aug 2005 immediate 5. 14 12(3) Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 25 6. 30 18 7. 32 12(5)(a) 8. 36 18(2) The registered person must ensure that staff receive training in dementia care. The manager must audit staffs training needs in this area and produce an action plan to address. The registered person must review the mode of staff diciplinary to ensure confidentiality and prevent upset to service users. The registered person must ensure staff receive effective, quality supervision to assist them in their role. immediate. Plan to be devised by 2nd Sep 2005 From date of inspection 19th Aug 2005 From date of inspection 19th Aug 2005 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 8 Good Practice Recommendations The registered manager should consider refining the documentation regarding accident audits to enable at a glance information about service users accidents in order to influence practice and reduce accidents. Newgrove House J54 2920 Newgrove House V246173 19 August 2005 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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