Inspection on 05/06/06 for Nicholas House Care Home

This inspection was carried out on 5th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Nicholas House Care Home 05/06/08

Nicholas House Care Home 15/03/06

Nicholas House Care Home 25/10/05

Nicholas House Care Home 18/02/05

Nicholas House Care Home 12/07/04

Nicholas House Care Home 08/12/03

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Nicholas House Care Home 11 Church Street Haxey Doncaster South Yorkshire DN9 2HY Lead Inspector Beverley Hill Unannounced Inspection 5th June 2006 09:00 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.V295648.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 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@bntinternet.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.V295648.R01.S.doc Version 5.2 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. 15th March 2006 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 fifteen bedrooms. The West Wing, an extension of seven 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.V295648.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day with one inspector for the morning joined by a second inspector in the afternoon. Throughout the day the inspectors spoke to nine service users and one relative to gain a picture of what life was like for people who lived at Nicholas House. The inspectors also had discussions with the manager, deputy manager, one nurse, four care staff and catering staff. Documentation in relation to the assessments people had prior to admission and the care plans produced to meet assessed needs were examined. Also examined were medication practices, activities provided, nutrition, complaints management, fire safety, general cleanliness, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. The inspectors also checked to see that service users privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in their environment. Prior to the visit to the home the inspector had sent out a selection of surveys to service users, some family members, all staff members and professional visitors to the home. These were analysed on their return and comments checked out during the inspection. The home is currently registered for forty-one people but as the remaining three bedded room has been made into a shared room for two people a variation in registration will be completed shortly to reduce the numbers to forty. This will enable the conditions of registration to be removed. What the service does well: The home was pleasantly decorated and furnished with separate lounges for people to sit and join in activities. The main garden to the front of the building was well maintained and had places for people to sit. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 6 The home was very clean and tidy and domestic staff work hard to maintain the high standards. Service users spoken to were happy with the cleanliness of their bedrooms and the home in general. The home always made sure that people had an assessment prior to being admitted and this included peoples’ preferences. The care plans produced met the assessed needs and were kept up to date with changes. The home had a good record of National Vocational Qualification training and a large percentage of staff had completed NVQ Level 2 and 3. One care staff member was presented with a national award recently for, ‘young carer of the year 2005’ which was a very big achievement for them. Direct observation of practice takes place and this is a good means of monitoring staff skills. A residents’ handbook is provided in each of the bedrooms to ensure that service users are aware of the services provided by the home. What has improved since the last inspection? Service users have enjoyed more activities, although an activities programme has yet to be produced that will cover a larger range and a new system of obtaining peoples views about the home has been put into . The home had employed an activities coordinator who had improved the activities available for service users. This was to be improved further with the formulation of an activities plan and records of service user participation and satisfaction. A new complaints form had been formulated and staff members were more aware of the need to document complaints and concerns. The form had not been put into practice at the time of the inspection. Training in the protection of vulnerable adults and moving and handling had been completed for all staff apart from those on long-term sick leave. Some improvements were noted in ensuring service users were consulted about the care they received and the quality assurance system and questionnaires sent out to people had been simplified. The home had started the process of sending out questionnaires to service users and staff to obtain their views. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 7 The registered providers had supported the manager in developing their new role and responsibilities by employing a consultant to work with them on areas to further develop. The supervision and monitoring system for two staff members had been implemented. 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 Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 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 the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensured that service users needs were assessed prior to admission and included the service user and their representatives in the assessment process. EVIDENCE: Three service user files were examined in detail and each showed that an assessment of need had been completed prior to admission. The assessments were thorough and each section of need had been completed. The assessments referred to service user choices, for example in the preferred gender of the carer, preference for bath or shower and in the times they usually rise in the morning and retired at night. As the staff team was made up of both male and female carers choices could be accommodated. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 11 There was evidence that the home had obtained assessments for those service users funded by care management. This was important as it assisted the home in making the decision as to whether they could meet needs. There was also evidence that the home formally wrote to service users or their representatives following assessment to state the dependency level indicated as a result of the assessment. This letter was sent out in the welcome pack that included terms and conditions and funding arrangements. The home needed to clarify in the letter that they were able to meet the identified needs and during the inspection the administrator adjusted the letter format to accommodate this. Some service users spoken to were aware an assessment had taken place and that a care plan had been formulated to meet their needs. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users personal care needs were met in a way that respected privacy and dignity and the home ensured that people had access to health care services. Improvements were required in the administration of service users medication to prevent confusion and risks to health. EVIDENCE: Three care plans were examined in detail and they indicated that the needs highlighted in assessment were planned for. Care plans were updated as needs changed and evaluated on a monthly basis. There was evidence that care plans had been signed by the service user or their representative and referred to levels of independence, privacy and dignity. Some service users spoken to knew they had care plans and one spoke of having a review with their relative Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 13 present. One care plan was quite specific regarding the need for non-verbal communication to meet the service users needs. In discussions with service users and examination of documentation it was evident that they had access to a range of health care services and were supported in personal care tasks by staff that respected their privacy and dignity. Risks were identified in relation to nutrition, pressure sores, moving and handling and the use of bedrails. Generally daily recording had separate sheets that covered personal hygiene care tasks, elimination, social activities participated in and if visited by a health professional. The main daily record gave a brief statement about the service user and any issues that may have occurred. From the sample examined there was evidence that issues were followed on to the next shift. The management of medication needed some attention to ensure that policies and procedures were followed at all times with regards to signing the medication administration record after administration. Several missed signatures were noted in two of the three records examined and an appropriate warning sign for the storage of oxygen had been placed on the inside of the medication room. Others areas of medication management in relation to receipt, storage and stock control were appropriate. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements have been noted in the provision of activities, although service users are not receiving a full range of activities yet. A lack of information from care to catering staff could mean that service users nutritional needs are not met. EVIDENCE: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements have been noted in the provision of activities, although service users are not receiving a full range of activities yet. A lack of information from care to catering staff could mean that service users nutritional needs are not met. Some activities had been arranged for service users and there was evidence in discussions that these were well received. The new activity coordinator was in Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 15 the process of developing an activity plan to meet a range of needs and this will be displayed in the home. They had completed discussions with service users able to express wishes and preferences and although the social activity provision was in the early stages there were signs of improvement. Choices and preferences were indicated in assessments and care plans and service users spoken to confirmed that their wishes were adhered to regarding times of rising and retiring, preferences with bathing arrangement, personalising their bedrooms and general choices about meals and gender of carer. Catering staff provided a list of available alternatives to the two main choices at lunchtime. Service users spoken to were happy with the meals provided and stated that catering staff visited them each morning for their choices. A discussion with the chef and examination of documentation indicated an inconsistency in the amount of information passed from care to catering staff regarding service users likes and dislikes, preferences, allergies etc, although this information was available in the service users initial assessment. This means that catering staff could be unaware of the full nutritional needs of service users. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 16 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 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in complaints documentation will ensure that the outcome of the investigation and whether this meets complainant satisfaction is documented. EVIDENCE: The home had received two complaints since the last inspection and had documented them. There had been a change in the complaints documentation since the last inspection, which would address the shortfall regarding documenting complainant satisfaction with the investigation and outcome, but this had not been put into practice yet. The current complaints log had out of date guidance for staff, which was mentioned at the last inspection. This needs to be addressed. An up-to-date complaints procedure was displayed in the home and service users spoken to were able to tell the inspector who they would complaint to. However some feedback cards from relatives indicated they were unaware of the complaints procedure or inspection reports. The home had completed training for all staff in the protection of vulnerable adults from abuse and increases in supervision and monitoring satisfied the inspectors that service users health and welfare would be promoted and Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 17 protected. Policies and procedures were in place to guide practice and discussions with the registered manager indicated their awareness and knowledge of adult protection issues and referral processes. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 18 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, 20, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a clean, safe and accessible environment for service users and they had the opportunity to personalise their bedroom to their own taste. 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. Survey comments from one person indicated that the main lounge looked like a waiting room and there was some substance to this. However the focus of the room was the television and chairs were arranged for this to be viewed. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 19 The manager should speak to service users regarding their preference for seating in this lounge. 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. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although improvements had been noted in mandatory training there were still gaps to address and adjustments to be made to the recruitment process to promote the safety and welfare of service users. EVIDENCE: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although improvements had been noted in mandatory training there were still gaps to address and adjustments to be made to the recruitment process to promote the safety and welfare of service users. The home provided sufficient nursing and care staff throughout the day and night and current staff vacancies were covered by existing staff and agency workers, until recruitment was finalised. Although the home strove to use the same agency staff, service users would be supported more consistently, by care staff employed by the home. Two staff now started at an earlier time to support service users who wished to rise earlier. Some surveys returned Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 21 indicated the home did not appear to have sufficient staff on duty and that staff could be more proactive in sitting and talking to service users. Service users spoken to were generally complimentary about the staff. They stated they were nice, friendly, had a good approach and they got on well with most of them. One person stated that they have different personalities and you can have a laugh and a joke with some. The inspector observed good interaction between several staff members and service users. The manager had devised a basic training plan to incorporate mandatory training and updates and although progress had been made with staff training there were some gaps noted. The company had moving and handling trainers and it was in this area as well as adult protection training that the home had made the most progress. The home had a very high percentage of care staff trained to NVQ Level 2 and 3, which was an achievement and one care staff member was voted, ‘young carer of the year’ in 2005 and was recently presented with her award. There was the opportunity for nursing and care staff to participate in training other than mandatory. The homes recruitment processes were generally sound. Although the manager had obtained conflicting information about the portability of criminal records bureau checks the home had followed appropriate procedures and applied for a new check. However stringent supervision arrangements must be in place during the time between a povafirst register check and return of a satisfactory criminal records bureau check. Arrangements to evidence the stringent supervision arrangements for the new staff member were put in place straight away after the inspection. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 22 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, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There had been improvements noted in the overall management of the home and the registered managers leadership and guidance skills. Service users health, safety and welfare will be increased with improved staff supervision, consultation with them about how the home is managed and attention to fire regulations. EVIDENCE: The previous proprietors had completed most of the management tasks usually the domain of the registered manager and the change of ownership had meant a reassessment of the managers’ leadership and guidance skills. It was noted Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 23 that these areas needed improvement. However support from a consultant, extra training completed and supervision with the new proprietors has indicated that the manager is progressing well in these areas. Staff surveyed felt they could approach the manager with issues and that these would be addressed. A new quality assurance system had been started to audit the services provided by the home and service user satisfaction. The home does not manage the finances of service users but keeps safe a small amount of personal allowance for several, usually deposited by relatives. This was managed and recorded appropriately, and was accessible to service users as required. Some people chose to manage their own personal allowance and facilities to keep this, and other personal items safe, was available in bedrooms. There had been some attempt at broadening the supervision process to include discussions with the staff member as well as the observations of practice but examination of records and discussions with staff indicated this was not consistently done. The one to one time during supervision was an opportunity for staff to discuss any concerns they have as well as the supervisor checking out training needs, service user issues, recording techniques and a general exchange of information. Two staff members continued to be supervised on a more frequent basis and documentation evidenced discussions and progress. It was noted that two bedroom doors were wedged open, one with an upturned stool. This was a trip hazard to service users and staff as well as contravening fire regulations and an immediate requirement notice was issued. Fire drills and alarm tests were carried out although it was noted that some staff required updates in fire training. Risk assessments had been completed and some service users had been assessed by an occupational therapist for appropriate seating. Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 24 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 25 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 OP36 Regulation 18(2) Requirement Timescale for action 30/06/06 2. OP12 16(2)(n) 3. OP31 9 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)(previous timescale of 31/05/06 not consistently met). The registered person must 31/07/06 ensure that the range of activities is expanded to provide stimulation for all service users in accordance with need choices and abilities (previous timescale of 12.5.06 not met fully although it is acknowledged that this process has started). 16/06/06 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. Still within timescale. DS0000002794.V295648.R01.S.doc Version 5.2 Nicholas House Care Home Page 26 4. OP9 13(2) 5. OP9 13(2) 6. OP15 12(1)(a) 7. OP16 12(1)(a), 17 8. OP27 18 9. OP29 19 10. OP30 18 11. OP31 9 12. OP33 24 The registered person must ensure that all medication is signed for consistently after administration. The registered person must ensure that a statutory warning sign is in place where oxygen is stored and used. The registered person must ensure that catering staff receive full information about service users nutritional needs. The registered person must ensure that the new complaints form for indicating service user satisfaction with the results as investigation is put into practice. The registered person must ensure that more staff are recruited to enable less reliance on agency staff and more consistency for service user care and support. The registered person must ensure that stringent supervision arrangements are in place for new staff in between receiving a povafirst check and a satisfactory Criminal Record Bureau check. The registered person must ensure that mandaory training and updates are completed in line with the homes training plan. The registered person must ensure that the manager continues with the good progress made in developing managerial skills. The registered person must ensure that the new system of monitoring the quality of the services provided is continued and results of service user satisfaction surveys are made available and a copy forwarded to CSCI. DS0000002794.V295648.R01.S.doc 30/06/06 30/06/06 30/06/06 30/06/06 31/07/06 30/06/06 31/10/06 30/09/06 30/09/06 Nicholas House Care Home Version 5.2 Page 27 13. OP38 13(4) The registered person must ensure that the two fire doors are not wedged open and appropriate action taken to ensure the bedroom doors can remain in the open position should the service user’s choice or needs dictate. 19/06/06 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 The Activity Coordinator should record service user participation in and satisfaction of activities and display the prrogramme when produced. The registered person should ensure that out of date information in the complaints log is discarded is replaced to avoid staff confusion and ensure that visitors to the home are aware of the ocmplaints process in iight of surveys received by CSCI. 2. OP16 Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, 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 © 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 Nicholas House Care Home DS0000002794.V295648.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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