CARE HOMES FOR OLDER PEOPLE
Nicholas House Care Home 11 Church Street Haxey Doncaster South Yorkshire DN9 2HY Lead Inspector
Beverley Hill Unannounced Inspection 15th March 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Nicholas House Care Home Address 11 Church Street Haxey Doncaster South Yorkshire DN9 2HY 01427 752862 01427 752251 islecare@bntintrenet.com 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) Isle Care (Axholme) Limited Mrs Alison Victoria Turner Care Home 41 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (41), Physical disability (20), of places Physical disability over 65 years of age (20), Terminally ill (5) Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 10 day care places available The home, after discussions with service users and their families, confirms in writing that the service users are in agreement to continue sharing the three-bedded room. The three-bedded room in its current form to be used only for the three existing service users. Any vacancies that occur will be filled up to a maximum of two people sharing the room in order to comply with Standard 23. 25th October 2005 Date of last inspection Brief Description of the Service: Nicholas House is situated in the village of Haxey, North Lincolnshire. The home is close to local amenities in Haxey, including shops, public transport and public houses. The home has its own mini bus. The original building is listed and opened as a residential home in 1988 with twenty-five bedrooms. The West Wing, an extension of six bedrooms, was completed in 1989 and The Coach House extension added a further nine bedrooms in 1993. In 2005 three en-suite single bedrooms were provided. Accommodation is provided over two floors and the home offers residential and nursing care for up to forty-one service users who may have needs associated with old age, dementia and physical disabilities. The Upper East Wing has nine bedrooms designated as a separate unit for people with complex needs associated with dementia. It has a separate lounge/dining room and dedicated staff. There are four other lounges, one of which is designated for smokers and a pleasant conservatory. The home also has two dining rooms set out with separate tables and chairs. The home has twenty-eight single bedrooms and six shared bedrooms. The home has sufficient bathrooms and toilets to meet the needs of people who live there. Outside the building there are garden and courtyard areas. Car parking is provided to the front of the home. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over one day and the proprietor was notified the day before to ensure their presence and access to records, as the manager was unavailable. Throughout the day the inspector spoke to the proprietors, one nurse, one care staff member and seven service users. They examined records in relation to care plans, risk assessments, accidents, complaints, staff recruitment and training, staff rotas, activities, maintenance and servicing of equipment, quality monitoring, service user and staff meetings, disciplinary reports and staff supervision and monitoring records. The inspector conducted a partial tour of the building. What the service does well: What has improved since the last inspection?
The new proprietors, registered manager and staff team have worked well to ensure that requirements issued at the last inspection have been addressed. The morale of staff was affected by the adult protection investigation and those
Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 6 spoken to were making a real effort to keep positive and ensure that poor practice was not tolerated. People who live at the home are afforded more protection from abuse because of staffs increased awareness of policies and procedures. Most of the staff team have received training and the rest will receive the training in the near future. The manager has improved recording generally and writes down any discussion she has with staff about concerns or any disciplinary measures she takes with staff. The manager is also due to participate in extra training in the protection of vulnerable adults from abuse at the end of March 2006. Staff members have more awareness of the need to follow policies and procedures, care plans and risk assessments and not move and handle people without the correct equipment or using the correct techniques. The new proprietor has demonstrated, through staff dismissal, that any infringement of policies and procedures or staff not following care plans and risk assessments will not be accepted. Care plans and risk assessments have been updated to include all relevant information to enable staff to work safely. The staff members have made more effort to write down all the care that they provide to people and that information follows on to the next shift. This is important to make sure that care is not missed. Service users spoken to stated that staff supported them in ways that maintained their privacy and dignity. The improvements noted in moving and handling techniques confirmed this. The home had ensured that six service users have had their seating and moving and handling needs assessed by a physiotherapist. There were eight people with dementia who lived in a unit within the home. The manager had reorganised the night shift routine to ensure they had more monitoring during the night. The staff members had made sure that all accidents and incidents were recorded. When the main kitchen was not in use it was made inaccessible to service users who may wander in. What they could do better:
Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 7 The home could improve the activities available for service users to participate in to improve quality of life. The recent employment of an activity coordinator should address this shortfall. The home could make sure that all complaints, concerns and niggles are documented so that the staff and the manager can keep track of them and record the complainants satisfaction with any investigation and outcome. The home needs to make sure that the remaining staff who have not completed mandatory training and in the protection of vulnerable adults from abuse complete it quickly. The manager could improve the consultation processes within the home to ensure that service users have more say in how the home is managed. The results of questionnaires, about the services provided, completed by service users and other visitors to the home could be written in a more accessible format for service users and a copy forwarded to the CSCI for examination. The questionnaires themselves could be simplified. The formal supervision that staff members receive still needs to include time for one to one discussions so staff can talk about any concerns they have. Direct observation of practice takes place and this is a good means of monitoring staff skills. The supervision/monitoring system for two staff members could have been more fully implemented. 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. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 8 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 Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed at this inspection. Standard 3 was met at the last inspection and the home does not provide intermediate care services. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 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 the following standard(s): 7, 8 and 10 There have been improvements in recording and the updating of care plans and risk assessments when service users needs change. This has resulted in a more effective response to meeting service users health and personal care needs. EVIDENCE: These three areas were assessed in detail at the last inspection but re-visited at this inspection to examine progress made with requirements. Care plans were generally comprehensive and covered assessed needs. Since the last inspection staff members have ensured that care plans and risk assessments were updated when needs changed, evaluated on a monthly basis and followed accordingly. Several service users had their moving and handling needs assessed by a physiotherapist and risk assessments completed. Daily recording regarding the care provided had generally improved, although there was still a tendency for some staff to write comments like, ‘no concerns’ for the report covering their shift. However daily bathing or personal care, activities participated in, visitors received, family or professional, and
Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 11 individual monitoring charts were logged elsewhere in the care file. When cross-referenced, the recording of accidents corresponded to daily recordings. Personal care records regarding bed baths, showers, immersion baths etc had a code/signature entry for morning and evening support. Definitions of the codes used by staff were indicated on the form. When cross-referenced with service users choices and wishes indicated in the initial assessment, the codes proved rather confusing and in some cases did not match up. This was discussed with the deputy manager who will investigate the anomalies. Service users spoken to state that staff supported them in ways that promoted their privacy and dignity. The inspector observed staff members knocking on doors prior to entering bedrooms and delivering mail unopened. Improvements in moving and handling techniques and the following of care plans and risk assessments ensured that service users privacy and dignity was maintained. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 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 the following standard(s): 12 and 14 A lack of activities over the previous few months has affected the quality of life for service users, however the employment of a new activity coordinator will address the shortfall. EVIDENCE: The inspector examined the activity file. There was no structured plan in place or an, ‘at a glance’ log of who had participated in activities. This would establish who had not participated and investigations as to why could be made with adjustments to the activity programme. Service users spoken to recognised there had been a shortage of activities lately but were pleased this was to change. An activity coordinator had very recently been employed to work at the home for three days a week. Via discussion with them it was apparent that they had plans to address the provision of activities in the main unit, which had been limited of late. They had spoken to each of the service users and lists had been made of their interests, likes and dislikes in order to tailor an activity programme. Some service users had chosen to participate in life story work to pass on to their relatives when completed. The inspector observed an activity provided by the coordinator. Five service users participated in listening to music and had discussions about each of the
Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 13 pieces and the memories it evoked, especially about their lives during World War 2. There was obvious enjoyment and expressions of emotions with one service user stating, ‘ it’s the most pleasant afternoon I’ve spent for a long time’ and another, ‘I enjoyed it very much, it was very nostalgic’. Service users with complex dementia care needs had separate activities provided by staff members that were present throughout the day in the upper east wing. Staff supported them to complete craftwork, which was displayed in the unit. This small group interaction, sometimes on a one to one basis was very beneficial to service users. Service users spoken to in the main unit state that routines were flexible, they could see their visitors in private and could make choices about various aspects of their lives. Some people looked after their own money, had installed their own telephones and bedrooms were personalised to varying degrees. Two people told the inspector they liked to do their ‘own thing’ and this was respected by staff. One liked to stay in their own bedroom and watch sport on TV but staff ‘popped their heads in’ through the day. Another stated that if you wanted to stay in bed to have a lie-in or if you just felt a bit, ‘off’, this was ok. The proprietors advised that menus were to be a discussion item with the new catering staff. This will be assessed in more detail at the next inspection. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18 Complaints and concerns were not documented consistently. Service users were more protected with staffs increased knowledge and awareness of adult protection policies and procedures. Not all staff had completed training in the protection of vulnerable adults from abuse. EVIDENCE: The inspector examined the complaints records. The last was recorded in August 2005. The record was an exercise book that did not fully detail complainant satisfaction or outcome at the end of the investigation. Service users spoken to had no complaints, however they stated they would tell relatives or the manager if they had. Staff members stated they deal with any concerns there and then but don’t necessarily document them all. There was an awareness however that an audit trail was required to evidence that complaints, concerns or general niggles have been addressed. A discussion with a relative during the inspection indicated that a complaint had been made recently that had been resolved to the satisfaction of the complainant, however the inspector could find no documentation relating to the complaint. The new proprietors will be introducing the complaints system that they have in place in other homes within the company. The home had a complaints policy and procedure and this was displayed in the entrance. The home also had a suggestion box, which was located in the entrance.
Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 15 Since the last inspection most care staff had received training from an external facilitator in the protection of vulnerable adults from abuse. Two nurses, seven care staff, seven ancillary staff and three bank staff members have still to complete the training. All staff members have been part of meetings to discuss adult protection and have been made aware of their responsibilities in reporting any areas of concerns immediately to the manager, person in charge of the shift or the proprietors. Two staff members were re-instated after a disciplinary hearing and ongoing monitoring systems and supervision were put in place. However the managers’ absence resulted in the monitoring plan not being fully operational until further arrangements could be made. These were due to start next week. The new proprietor had moving and handling trainers within the company and most staff members had received updated training to ensure service users were moved and handled safely according to policies and procedures. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 22 Improvements were noted in the seating provided to specific service users and the home was generally a clean and well-maintained environment. EVIDENCE: The home is a mixture of old and new buildings over two floors, is serviced by a lift and has ramps to the entrances. The home continues to be very clean and tidy and service users spoken to were happy with their home in general and with their individual personalised bedrooms. One service user stressed to the inspector that they gave the home, ‘first marks’ for the laundry, ‘it is taken away one day to be washed and returned the next’. Other service users participating in the conversation agreed. The home was pleasantly decorated and well maintained. The home complied with fire and environmental health regulations and staff members ensured that the kitchen was locked when not in use. The last multiple occupancy bedroom had been made into a large shared room for two service users. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 17 Since the last inspection a physiotherapist had assessed six service users regarding their seating and moving and handling requirements. For safety reasons one chair had been removed from use and another sited in a different position in the lounge. Further slings for the hoists were recommended and purchased. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Improvements were noted in the deployment and training of staff. Not all staff had completed mandatory training, which could place service users at risk of inadequate care. EVIDENCE: The home provided support for eight people with dementia in the upper east wing. There was always a staff presence on the unit during the day and a new system of staff deployment during the night was tried after the last inspection. This resulted in some care issues for the other night staff worker at one end of the building and the situation was reviewed again. Night staff now complete hourly checks on service users in the upper east wing and so far this has proved effective. Three recruitment files of new staff were examined and all contained appropriate documentation. Criminal record Bureau checks were in place prior to the start of employment. Robust recruitment practices were important for the protection of service users. The manager had produced a training plan for the year. This covered mandatory training and NVQ Level 2 and 3. Staff had access to a range of inhouse training, distance learning, videos and external facilitators. Out of twenty care staff, sixteen had completed NVQ Level 2 or 3, which was an achievement. All domestic staff were undertaking NVQ Level 2 in housekeeping and a catering staff member NVQ Level 2 in catering. The training plan
Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 19 indicated that not all staff had completed or had up-dated certificates in mandatory training. The company had moving and handling instructors and most staff completed moving and handling training and updates in February and March 2006. Staff members received a competence certificate after moving and handling training and were expected to work safely. One staff member had completed new moving and handling training, was aware of care plans and risk assessment but they still moved and handled a service user inappropriately and so was dismissed by the proprietors. An ongoing monitoring process, which includes supervision, was in place to ensure the skills that staff members learned through training were put into practice. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 and 38 Although some improvements were noted in some of the management systems in the home, the support action plan including full re-induction set up following disciplinary measures for two staff and general staff supervision was affected by the managers absence resulting in practice not being monitored as initially planned. Improvements were required in the homes consultation processes to ensure greater service user participation and decision-making in the running of the home. EVIDENCE: The previous proprietors played a large role in the management structure of the home, however the new proprietors have introduced a short-term management support system for the continued development of the registered managers’ leadership skills. This was due to start the week commencing 20.3.06. The proprietors must monitor the support system and write to the
Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 21 CSCI with details of objectives, how improvements are to be measured and a final analysis of the managers’ achievements of these objectives. Since the last inspection the registered manager has made improvements in recording discussions with staff and those of a disciplinary nature, and general record keeping. There had been some evidence of staff supervision since the last inspection but not all staff members were on track to receive six supervision sessions per year. A supervision log was maintained and observation of practice completed, for example, bed-bathing, changing a dressing or assisting with personal care. There had been some one to one discussions to accompany observations of practice but these needed to be evident in all care staff members’ supervision sessions. 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. The manager must ensure that effective formal supervision of staff continues to take place. It had been planned that two staff members were to receive more frequent supervision and monitoring of their practice due to disciplinary measures. Although the overall monitoring plan had been affected by the managers recent absence this was due to be addressed the next week by a system of monitoring and support organised by the proprietors. The home had a quality monitoring system, which consisted of questionnaires, audits and monthly meetings of a quality action team made up of the manager, the administrator, two relatives and two staff members. The questionnaires for service users views were lengthy having thirty-five questions on a range of topics and ten were distributed each year. Questionnaires were also sent to relatives, staff and GP’s. The views of other professional visitors such as care management and district nurses could be obtained for a wider picture. The quality assurance coordinator was currently looking at simplifying the process with shorter questionnaires and more service user views/consultation obtained. Results of questionnaires were distributed in a newsletter but they could be simplified and made easier for service users to read and understand. There was evidence that the home had held two service user meetings in the last year and although it was suggested that staff obtained service users views on a daily basis about aspects of the home these were not recorded in any way. The home does not manage the finances of service users, however a small amount of personal allowance was held at the home for hairdressing and chiropody. This will be assessed in detail at the next inspection. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 22 Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x x 3 x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x x 2 x 2 Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP18 Regulation 13(6) Requirement Timescale for action 31/05/06 2 OP30 3 OP36 4 OP12 The registered person must ensure that all staff receive further awareness training in their duty of care responsibilities and adult protection alerting and referral procedures (previous timescale of 31/03/06 not met) 12(1)a The registered person must &18(1)c(i) ensure that all staff put into practice their moving and handling training. The manager must ensure that all staff have a current up to date certificate in moving and handling by an accredited trainer (previous timescale of 13/01/06 not met) 18(2) The registered person must ensure that formal supervision process is expanded to include regular one to one discussions relating to care practices, service user and team issues, and the values expected to be upheld within the home (previous timescale of 31/01/06 not met) 16(2)(n) The registered person must ensure that the range of activities is expanded to provide
DS0000002794.V285462.R01.S.doc 30/04/06 31/05/06 12/05/06 Nicholas House Care Home Version 5.1 Page 25 5 6 OP16 OP18 22 18 7 OP31 9 8 OP31 9 9 10 OP33 OP33 24 24 11 OP38 12(1)(a) & 18 stimulation for all service users in accordance with need choices and abilities. The registered person must ensure that all complaints and concerns are recorded. The registered person must ensure that the monitoring plan initiated for two care staff is implemented fully. The registered person must ensure that the registered manager continues to receive support and guidance. The registered person must provide the CSCI with information regarding set objectives for the manager, how these are to be measured and a final analysis of how effective the support structure has been. The registered person must ensure that service user consultation is increased. The registered person must ensure that the quality survey is expanded to include the views of other stakeholders such as D/N’s and care management and a copy of the quality survey results are forwarded to the CSCI The registered person must ensure that mandatory training is planned for completion, skills learned are put into practice and monitoring processes are robust to ensure the safety of service users. 30/04/06 21/04/06 21/04/06 16/06/06 30/04/06 31/05/06 21/04/06 Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP8 OP12 OP33 Good Practice Recommendations The registered manager should ensure that codes used to indicate personal care tasks are clear. The Activity Coordinator should record service user participation in and satisfaction of activities. The registered person should consider making the results of surveys clearer and more accessible to service users. Nicholas House Care Home DS0000002794.V285462.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor 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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