CARE HOMES FOR OLDER PEOPLE
Ringway Mews Nursing Home Stancliffe Road Sharston, Wythenshawe Manchester M22 4RY Lead Inspector
Geraldine Blow Unannounced Inspection 21st February 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 Ringway Mews Nursing Home DS0000021656.V278876.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. Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ringway Mews Nursing Home Address Stancliffe Road Sharston, Wythenshawe Manchester M22 4RY 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) 0161 491 4887 0161 428 6991 www.bupa.com BUPA Care Homes (CFHCare) Limited Stephanie Maginn Care Home 150 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (120) of places Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. All service users require nursing care. The number of service users for whom accommodation is provided at any one time shall not exceed 150 patients of either sex aged 60 years or over. Up to 30 service users who are over the age of 60 and who additionally have dementia may be accommodated on Halifax Unit. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 29th June 2005 Date of last inspection Brief Description of the Service: Ringway Mews is a care home providing nursing care and accommodation for a maximum of 150 older people. Within this maximum number, accommodation is provided for 30 older people with dementia type illnesses. However, at the time of writing this report one of the houses that provided nursing care was closed. The home is owned by BUPA Care Homes. The home is situated in the residential area of Wythenshawe, which is to the South of the City of Manchester. There is easy access to the Manchester ring road motorway system as well as easy access to public transport systems, which are within walking distance of the home. There is ample parking within the grounds of the home. Wythenshawe Civic centre is easily reached by car and there are local shops, which are within walking distance of the home. The home is purpose-built and consists of 5 separate single storey houses. Each house provides accommodation for 30 residents and stands within its own garden area. The administration area, laundry, hairdressers, and central kitchen are housed in a central building that is accessible by a covered walkway. Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced, conducted by 2 inspectors and took place on Tuesday 21st February 2006. During the course of the inspection time was spent talking to the Responsible Individual, the deputy manager, some residents and several members of staff to find out their views of the home. Time was spent examining records, documents, residents and staff files. A tour of two of the houses was also conducted. On the day of inspection the Pharmacist Inspector also visited the home to undertake a specialist pharmacist inspection. A number of concerns were identified and discussed with the Responsible Individual and the deputy manager. A separate report will be produced containing her findings. Since the last inspection in June 2005 the Commission for Social Care Inspection (CSCI) has received 2 complaints about the home and 2 allegations of abuse have been made. The 2 complaints were found to be upheld in part and the 2 allegations of abuse have been appropriately investigated and were also upheld in part. Due to the 2 allegations of abuse the contracts department suspended admissions to the home, which is standard procedure. That suspension has now been lifted. During June 2005 1 resident at the home and 1 former resident were identified as having Hepatitis B. During this time a thorough investigation was conducted and the home worked very closely with The Health Protection Unit, South Manchester PCT, Infection Control and CSCI. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. What the service does well:
Of the standards assessed during this inspection the home does well in the following areas. The houses visited were clean and nicely decorated. One resident told that inspector that the home was “always lovely and clean and that she had a very nice bedroom”. The atmosphere on Lancaster House felt comfortable and relaxed. The residents spoken to were nicely dressed, chatty and appeared happy. One resident said that she liked the home and was satisfied with everything.
Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 6 One resident told the inspector that she was very happy at the home and had never had to make a complaint but if she did have a compliant she would go to the nurse in charge and she was sure that they would sort it out for her. Meals times appeared to be a relaxing, social occasion and feedback with regard the quality and quantity of food was positive. One resident stated that she was a vegetarian and she had never had a problem with the food. She said that you could have snacks and drinks whenever you wanted. The Responsible Individual and the home manager are honest, open and transparent in their management approach. They are working hard to ensure that the National Minimum Standards are met and have worked closely with CSCI. From the systems in place it appeared that the financial interests of residents are safeguarded. What has improved since the last inspection?
Since the last inspection the home had worked hard to improve the care plans and put new care plan documentation into place. The majority of staff have attended care planning training and this will be an ongoing process until all staff in the home have received it and reach the required standard. Also, as part of the interview process all qualified nurses must develop a care plan, which meets the minimum standard, before a job will be offered. In general the care plans were much improved. However, some shortfalls were still identified and are detailed below. A Consultant Psychiatrist in Dementia Care has assessed the care on Halifax House, which is the Dementia Care Unit and produced a report, which contains a number of recommendations. The progress of these recommendations will be assessed at the next inspection. Since the last inspection the home appeared much cleaner and the requirements made in relation to this had been met. Two of the houses have had new lounge carpets, several bedrooms have been re-decorated and several offices have been redecorated. All the wheelchairs had been cleaned and equipment was appropriately stored. The leaking shower cubicle, on Lancaster House, identified at the last inspection has been replaced with a new walk in shower and new bathroom flooring has been laid. The use of communal toiletries had stopped and all residents had been given their own.
Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 7 What they could do better:
As already stated in this report, although the standards of the care plans were greatly improved some shortfalls were identified. Evidence must be provided that the care plans are drawn up with the involvement of the resident or their representative. The plans of care must not contain vague statements, they must have detailed information so that care staff are aware of the action to be taken to meet residents’ needs. All care plans must be accurately reviewed on a regular basis. On the day of inspection the nurse on Lancaster House was unable to find the adult protection procedure and he told the inspector that he had not received any training on what action to be taken in the event of an allegation of abuse. Also the deputy manager had some difficulty in finding the procedure. This has the potentional to put residents at risk. The adult protection procedure must be easily accessible to all staff and contain the information relevant for making referrals to the appropriate local authority. Providing staff with the necessary training and making sure that the staff maintain those skills through up-dated and refresher training is important to make sure that the residents needs are being met correctly. The staff training records showed that many members of the staff did not appear to have undertaken the necessary training. All staff must undertake the necessary training and have an individual staff training and development plan. The homes recruitment of staff must ensure that all the necessary checks are done in order to make sure that staff are safe to work with the residents. The Responsible Individual of the home said that the quality audit system was in the process of being reviewed. The new system must include the views of residents and their representatives and an action plan to improve the service must then be produced. There was an unpleasant odour in the entrance hall of Halifax House. This is an on-going issue at the home and was discussed with the Responsible Individual. The Pharmacist Inspector did a Specialist Visit of the Halifax Unit on 21 February 2006 and found that the concerns arising from this unit were significant and many had been highlighted at the previous inspection on 26 June 2005. It is of serious concern that little improvement had been made or maintained with regard to all aspects of medication handling. It is of concern that the health and wellbeing of the residents continues to be at risk. Nurses are not abiding by the Nursing and Midwifery Council guidelines for the administration of medication and a letter went out on 16 February 2006 detailing her findings. The requirements and recommendations made by the
Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 8 Pharmacist Inspector are included in the requirements and recommendations listed below. 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. Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 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 Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 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): No judgements were made at this inspection EVIDENCE: In order to meet the requirement made at the last inspection that all residents are provided with terms and conditions in respect of accommodation to be provided including the amount and method of payment of fees had been met by the home producing a letter that is sent to the residents prior to them moving into the home. It is recommended that all the points listed in Standard 2.2 of the National Minimum Standards be included in the letter with particular reference to periods of notice. An emergency admission policy had been developed and had been included in the Statement of Purpose, as required at the last inspection. The core standard was assessed at the previous inspection. Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 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 the following standard(s): 7 Each resident had an individual plan of care. However, some areas of documentation required improvements to ensure residents health, personal and social care needs are fully met. These shortfalls have the potential to place residents at risk. EVIDENCE: A random sample of care files were inspected and found that the standard of care planning had greatly improved and it was obvious the home had worked hard to improve the overall standard. Each file contained a photograph for easy identification and the requirements made at the last inspection in relation to risk assessing the use of bed rails and the use of ‘kirton or bucket’ chairs had been met. However, a number of shortfalls were identified in the files inspected, particularly on Lancaster House, which are detailed below: • Evidence could not be provided that the care plans had been drawn up, where possible, with the involvement of the resident or their representative. The nurse told the inspector that discussions had taken place with the resident’s family but no evidence could be found to support this.
DS0000021656.V278876.R01.S.doc Version 5.1 Page 12 Ringway Mews Nursing Home • • • • • • A risk assessment for the use of bed rails had been completed but the section to be signed by the home manager had not been filled in. A manual handling assessment had identified that a slide sheet must be used as an aid to sit the resident up in bed. This had not been incorporated into the care plan. The intervention section of one care plan stated, “staff should be aware of the” residents “needs”. Other plans of care had vague statements for example requires “regular checks during the night” and “requires assistance to promote a safe environment due to her medical condition”. The nurse was unable to explain the last statement. One care plan stated “turn every 2 hours while in bed”, when asked for the evidence that this had been carried out the nurse said that the resident does not need turning in bed because she can turn herself while in bed. It had been documented that the monthly reviews had taken place yet this error had not been identified. One care plan identified that the resident required assistance with her personal care yet this was contradicted in the daily progress record that consistently recorded “self caring with hygiene”. A daily progress record of care had been kept, however the standard of documentation was found to be variable. It is recommended that these records include more detail to accurately reflect the nursing care provided over a 24-hour period. As already identified in this report the pharmacist inspector has undertaken a specialist pharmacist inspection. A number of concerns were identified and discussed with the Responsible Individual and the deputy manager. A separate report will be produced containing her findings. The remaining core standards were assessed during the previous inspection. Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 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 the following standard(s): 15 The home served meals that were nutritious, healthy and balanced. EVIDENCE: The inspector observed lunchtime to be a social occasion with staff promoting a relaxing, friendly atmosphere. The lunchtime meal on the day of inspection was soup, Shepard’s pie and fruit pie, which looked and smelt appetising. Residents are asked a day in advance for their choice of meals. Comments received by residents regarding the quality and quantity of food was all positive. Staff were observed to be pleasant and courteous in their conversations with residents during the meal. Sensitive interaction was observed when additional support was required by individual residents. The majority of residents were seen having lunch at the dining table or in the main lounge area. However, residents could have their meals in the privacy of their own rooms if they so wished. The remaining core standards were assessed during the previous inspection.
Ringway Mews Nursing Home DS0000021656.V278876.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 & 18 The home encourages and supports people to raise their concerns and complaints. Not all staff have received training in the Protection of Vulnerable Adults. The lack of training does not ensure that the people living in the home are protected from abuse EVIDENCE: The home has a complaint procedure that had been given to all residents and encourages people to raise their concerns and complaints. A record was kept of all complaints made and included details of the investigation and any action taken. The previous inspection report required the home to ensure that it has the necessary policies and procedures to respond to allegations and incidents of adult abuse. Although the home said that they had access to the Manchester Multi-Agency Adult Protection Procedures the actual document could not be easily found. In addition, the home supports residents who are placed by different local authorities and they did not have the necessary contact details for making adult protection referrals. The adult protection procedure must be easily accessible at all times and contain the information relevant for making referrals to the appropriate local authority. Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 15 One nurse spoken to told the inspector that he had not had any adult protection training and was unable to find the relevant policy on the unit. In order to protect the residents living at the home all staff must receive Protection of Vulnerable Training, which includes the actions to be taken in the event of an allegation of abuse. Ringway Mews Nursing Home DS0000021656.V278876.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): No judgement was made for these standards. EVIDENCE: All requirements made at the last inspection in relation to these standards had been met. The core standard was assessed at the previous inspection. Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 28, 29 & 30 The home was unable to clarify that its staff had the required qualifications and training to meet resident’s support needs. The home’s recruitment process and systems does not fully ensure that staff are safe to work with vulnerable residents. EVIDENCE: The previous inspection report required the home to undertake an audit of all the training undertaken by staff. It was seen that the system used for recording team and individual training had been updated and so met this requirement. However, it was noted that the audit showed that many members of the staff team did not appear to have undertaken some core mandatory training or refresher training such as Moving and Handling, Adult Protection, First Aid etc. It was also found that staff training records consisted of a training log and not a training and development plan that sets out the mandatory, refresher and service specific training staff require. All staff must undertake the necessary mandatory (including refresher) training and have an individual staff training and development plan. From September 2006 a new compulsory Induction Module programme is being introduced by Skills for Care (formerly TOPSS). BUPA have produced a Staff Induction programme that, it says, incorporates Skills for Care Induction Standards. It was found that the induction modules are in fact the old TOPSS
Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 18 modules and is not the compulsory Induction programme introduced by Skills for Care. The home must develop an induction programme based on the Skills for Care Common Induction Standards within the timescales stated. A copy of this must be provided to the CSCI. At the time of inspection the home was not able to provide written evidence of the numbers of staff who have achieved the NVQ level 2. The home must provide the CSCI with a breakdown of which staff have achieved the NVQ 2 (or above), those currently undertaking the qualification and those who have yet to start. The home has a system for the recruitment of staff and the process for undertaking the required checks to ensure that staff are suitable to work with vulnerable adults. This system includes requiring qualified staff to undertake an additional competency test relating to care planning. However, it was found that the home uses a set pro-forma to gather references. Completed forms were seen that claimed to be from a person’s previous employer. There was no evidence, such as a company stamp, to prove that the reference came from a previous employer. It is recommended that the home’s reference pro-forma provide clear evidence that the reference was from a previous employer. The home evidences that a person has a current Criminal Records Bureau (CRB) certificate by attaching the top portion inside the staff file. The example seen contained the certificate reference number and the date was hand written. And example was seen where the home had used the POVA first facility to start a care worker before the CRB certificate was available. The home must ensure that it follows the Department of Health guidance in that POVA first checks should only be used in ‘exceptional circumstances’. A staff file was seen where the person required a residence and work permit to work legally in the United Kingdom. It was found that the residency permit had expired and no up-to-date documentation was available. A current work permit was present but this related to the position of nurse and the staff was not a qualified nurse. There was also no evidence that the staff’s NMC registration had been extended as the staff was on the nurse adaptation programme. The home must ensure that it has up-to-date and relevant documentation for all staff who require work and residency permits to work legally in the United Kingdom. Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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 & 38 Systems and procedures were in place, which safeguards and protects residents’ financial interests and the home was seen to promote the health, safety and welfare of the residents and staff. EVIDENCE: The home’s manager was not on duty on the day of inspection. However, she was successfully interviewed and was registered with CSCI in November 2005. The residents in the home benefit from a committed and experienced Registered General Nurse (RGN) manager. She has a wide variety of nursing experience and has undertaken a wide range of training, which includes the registered managers award. The home does have a formal quality assurance system. However, it was acknowledged that the self-audit did not provide the information the home required and so this is being reviewed and a new quality assurance system will
Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 20 be developed. The home must develop and implement and quality assurance system that includes the views of residents and their representatives and leads to the production of an action plan for the further development of the service provided. The home has a clear and transparent system for managing and recording the personal finances of those residents that they previously had responsibility for through being the appointee. The systems had changed so that either the resident, their family/representative or the relevant local authority was responsible for the personal finances. All transactions and documentation was regularly audited and monitored both by the home and through the main organisation (BUPA). Evidence was seen that the home ensures the health, safety and welfare of the residents and staff are protected at all times. Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME 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 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 x x x x x x x x STAFFING Standard No Score 27 x 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 22 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 OP7 Regulation 15 Requirement 1. Residents care plans must be written with sufficient and accurate detail to provide clear guidance to staff of the actions to be taken to meet the residents health and welfare needs. 2. The plan of care, where possible, must be drawn up with the involvement of the resident in a style accessible to the resident. Once agreed it must be signed for by the resident whenever possible and/or their representative. (Previous timescale of 31/8/05 had not been met) 3. The plans of care and risk assessments must be accurately reviewed. 1. The Registered Person must ensure that staff administering medication adhere to guidance issued by the Royal Pharmaceutical Society and Nursing and Midwifery Council in respect of the safe receipt,
DS0000021656.V278876.R01.S.doc Timescale for action 21/03/06 2. 9 13 10/03/06 Ringway Mews Nursing Home Version 5.1 Page 23 administration and disposal of medicines in the home 2. The registered person must ensure accountability for all medication is evidenced by accurate record keeping. 3. The registered person must ensure the supplying pharmacy is contacted to discuss supply of medication. 4. The registered person must ensure a robust ordering system is implemented to ensure that medication is available for all service users. 5. The registered person must ensure that medication is stored within manufacturers recommended temperatures and that nurses are aware of what action to take in the event of medication being stored incorrectly. Medication must be stored securely at all times. 6. The registered person must ensure medication is administered in strict accordance with prescriber’s directions at all times. 7. The registered person must ensure that waste medication is removed on a regular basis and to ensure that unsafe levels of stock do not build up. 8. The registered person must ensure that all nurses administering medication undergo medication training. Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 24 9. Staff administering medication must have their competency to do so assessed. (Previous timescale of 29-06-05 had not been met) 1. The adult protection procedure must be easily accessible at all times and contain the information relevant for making referrals to the appropriate local authority. 3. OP18 13 21/03/06 4. OP28 18 5. OP29 19 2. Evidence must be provided that all staff have received Protection of Vulnerable Adult training which includes the actions to be taken in the event of an allegation of abuse. The home must provide the CSCI 01/04/06 with a breakdown of which staff have achieved the NVQ 2 (or above), those currently undertaking the qualification and those who have yet to start. 1. The home must ensure that it 01/03/06 follows the Department of Health guidance in that POVA first checks should only be used in ‘exceptional circumstances’. 2. The home must ensure that it has up-to-date and relevant documentation for all staff who require work and residency permits to work legally in the United Kingdom. 1. All staff must undertake the necessary mandatory (including refresher) training and have an individual staff training and development plan. 2. The home must develop an induction programme based on the Skills for Care Common Induction Standards within the timescales stated. 6. OP30 18 01/05/06 Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 25 7. OP33 24 A copy of this must be provided to the CSCI. The home must develop and 01/05/06 implement and quality assurance system that includes the views of residents, their representatives and visiting professionals and leads to the production of an action plan for the further development of the service provided. 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. Refer to Standard OP2 OP7 Good Practice Recommendations It is recommended that all points listed in Standard 2.2 of the National Minimum Standards are included in the letter sent to residents prior to admission. It is recommended that the daily progress record of care should contain more detail to accurately reflect the nursing care provided over a 24-hour period. It is recommended that the home’s reference pro-forma provide clear evidence that the reference was from a previous employer. 3. OP29 Ringway Mews Nursing Home DS0000021656.V278876.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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