CARE HOMES FOR OLDER PEOPLE
Ringway Mews Nursing Home Stancliffe Road Sharston Wythenshawe, Manchester M22 4RY Lead Inspector
Geraldine Blow Unannounced 29 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Ringway Mews Nursing Home Address Stancliffe Road Sharston Wythenshawe Manchester M22 4RY 0161 491 4887 0161 428 6991 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes (CFH Care) Limited No. 2741070 Responsible Individual - Ms Susan McLean CRH Care home N Care home with nursing 150 Category(ies) of DE(E) Dementia - over 65 30 registration, with number OP Old age 120 of places Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 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 Date of last inspection 21 February 2005 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 had been closed and the home had applied to the Commission for Social Care Inspection to register the unit for residents with dementia type illnesses assessed as requiring personal care only. 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 it’s 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 F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced, conducted by 2 inspectors and took place over the course of 6 ½ hours on Wednesday 29th June 2005. During the course of the inspection time was spent talking to the registered manager, the clinical home manager, residents, relatives and several members of staff to find out their views of the home. The Commission for Social Care Inspection (CSCI) Pharmacy Inspector carried out an inspection of the medication procedures and a separate report will be produced containing her findings. Time was spent examining records, documents, residents and staff files. A tour of the four houses that were currently accommodating residents was also conducted. Since the last inspection, in February 2005, the home has received 23 complaints. Of those complaints 12 were upheld, 9 were upheld in part, one was not upheld and 1 was inconclusive. Since the last inspection the home has had 2 allegations of abuse. One is still is the process of investigation and one has been appropriately concluded. The Commission for Social Care Inspection had recently been contacted by Crime Reduction Advisor for Greater Manchester. This person corresponded concerns about the number of crimes reported to the police by the home. A meeting has taken place and the home is currently working towards meeting the recommendations made by the Manchester Crime Reduction Team. During this inspection only a selection of the key National Minimum Standards were assessed therefore in order to gain the full picture of how the home meets the needs of residents this report should be read with the previous and any future reports. What the service does well:
Prospective residents have a pre admission assessment to ensure that the home can meet their needs. The home has large well maintained garden areas and there is a small sensory garden that residents and relatives can enjoy. Each house has its own garden area and Halifax House, which is registered to provide nursing care for residents with dementia has a secure garden area to allow safe access for residents. The garden areas had patio tables, chairs and parasols. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 6 The home employed 2 activity organisers who arranged group activities and individual activities for the residents. On the whole staff appeared to treat residents with respect and dignity. One member of staff was observed to knock on the resident’s bedroom door before entering. An example was seen where a resident was in the lounge area and asked for help to access the bathroom facility. Staff responded quickly with two staff supporting the resident to transfer to wheelchair and to the bathroom. One resident spoken to said, “I can come and go as I like”. Each resident is given a copy of the complaints procedure when they move into the home. One resident spoken to said, “its all right here. I have no complaints”. Another resident said, “I’ve lived here 7 years and never made a complaint”. Residents can receive visitors either in the quiet communal areas or their own bedrooms. A relative spoken to during the inspection expressed how ‘delighted’ he was with the care that the staff give to his wife. He said how knowing that she was being cared for and kept safe was very important to him. A number of bedrooms viewed had been personalised with such items as pictures, photographs, small pieces of furniture and one bedroom had 2 armchairs. Some of the bedrooms had patio doors leading directly into the garden areas. One resident had a birdbath and a bird table positioned outside his patio doors so that he could watch the birds while resting in bed. It was observed that the home had developed a 1940’s shop where residents could purchase small items. A ‘Snoozlen’ room has been established in Halifax House for residents to access. The room was used for therapeutic purposes and helped to reduce anxiety of residents. Several visitors were seen during the inspection. Visitors were seen in the residents’ bedrooms and in the communal areas of the home. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 7 What has improved since the last inspection? What they could do better:
Some areas of the home did not meet a satisfactory standard of hygiene. For example some of the lounge carpets were found to be quite stained. One of the baths was found to be dirty and stained. The requirement from the last inspection that the leaking shower cubicle on Lancaster House be fixed and thoroughly cleaned had not been met. Several of the wheelchairs were found to be dirty and contained encrusted food. During the inspection it was noted that several of the residents bathrooms were being used as storage space for equipment. This presents a significant risk to residents and must cease. It was also noted that one of the fire exits was being blocked with a trolley. The inspectors that was being stored in the bathrooms. The home must not use communal toiletries for residents. One of the bedrooms on Anson House was seen to have large cracks on the walls and the side wall of which the bed is positioned was found to have dirty marks on. The activity sheets on display in each house must be current and up to date. It was noted that the one on display in Halifax House was advertising Mothers day. The home must improve the plans of care for each resident to make sure that all their care needs are met. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 8 On Halifax house the 2 qualified staff on duty were taking their lunch break together. They were sat outside on the bench, however one qualified member of staff must be on duty at all times. The ability for staff to be able to talk and listen to residents is an important aspect of their care and support. Therefore staff need to be able to make themselves clearly understood and to be able to clearly understand what is being said to them. During the inspection staff were spoken to regarding their roles and responsibilities and the support needs of residents. It was difficult to clearly understand a number of staff and for them to clearly understand what was being asked of them. If this situation was repeated with residents then situations could arise where residents needs were not clearly identified and acted upon. 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 F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 5 Residents are only admitted to the home after a full assessment of needs has been undertaken. This ensures that residents care needs can be met. However residents were not provided with a Statement of Terms and Conditions with the home. EVIDENCE: At the last inspection a requirement was made that the responsible person must ensure that each resident is provided with a Statement of Terms and Conditions. This had not been met and has been reiterated in this report. The manager confirmed that BUPA only provide a contract with terms and conditions of residence for people who are privately self-funding. For people who are funded by a local authority there was no contract containing the information required from Standard 2 of the National Minimum Standards. Evidence was seen that prospective residents had a pre-admission assessment to ensure that the home could meet all of their assessed needs. The assessment included the involvement of the prospective resident, his/her
Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 11 representatives and any relevant professionals. The registered manager or the clinical home manager conducted the pre-admission assessment. For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. The requirement from the last inspection that the home must develop and implement an emergency admission policy had not been met. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 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 standard(s) 7, 8, 10 Each resident had an individual plan of care. However some areas of documentation required improvements to ensure residents health care needs are fully met. These shortfalls have the potential to place residents at risk. EVIDENCE: Each resident had an individual plan of care, however the standard of the care planning process and the documentation throughout the home was found to be inconsistent. Various care plans were found to lack detail of the action, which needed to be taken by care staff to ensure that all aspects of care needed by the residents, were met e.g. “toilet at frequent intervals” and “provide pressure relief”. The care plans must clearly identify what specific help is needed. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 13 Not all of the individual plans of care or risk assessments had been reviewed on a monthly basis. Evidence was seen that some risk assessments had been incorporated into the individual plans of care. However these must be further developed to include more detail and include all potential risks. There was little evidence that the plans of care had been drawn up with the involvement of the service user and/or their representative. The daily nursing report was vague and provided little indication of the actual care given. Evidence was seen that the home had developed a risk assessment format for the use of bed rails. However bed rails and wheelchair lap belts were being used without the risk assessments being undertaken. The requirement from the last inspection that the use of Kirtons chairs must be risk assessed and consent be obtained for their use had not been met. Staff appeared vague as to why certain residents were sitting it this type of chair. Evidence was seen of regular weight recordings however in the case of one resident there had been a steady loss of weight and no action appeared to have been taken by the home to address this. One resident was on PEG feeds and there was 2 consecutive days were there was no recording that the feeds had been given. Another plan of care clearly documented that pressure relief every3 to 4 hours was required and there was no evidence that this had happened. The manager reported that BUPA had set up a working party on the care planning process and subsequent documentation. Not all of the residents’ files contained a photograph, which would provide easy identification. Each resident was registered with a General Practitioner and evidence was seen of referral to other specialised services according to residents assessed needs. For example District Nurses, Tissue Viability Nurse, Dentist, Dietician and Chiropodists. The CSCI Pharmacy Inspector conducted an inspection of the medication procedures and a separate report will be generated. The home appeared to treat residents with respect and dignity. Examples were seen of staff talking with residents in a respectful and courteous manner. Staff members were seen to support a resident being transferred to a standing hoist. The staff spoke to the resident, telling her what they were doing and encouraging her. All communal lounges had a portable public telephone that residents could use. The induction programme included guidance on treating people with respect.
Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 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 standard(s) 12, 13 &14 The home appeared to provide a good environment for the residents who live there with some activities available. Residents were able to maintain contact with family and friends and were able to exercise choice and control over their lives EVIDENCE: The home has a weekly activity programme for the four units that are supported by two activity coordinators. The programme involved events such as day trips, music sessions, quizzes, bingo and videos with residents from each unit being offered two activities a week. The inspectors were told that the activity workers would discuss social/leisure activities with the residents to choose what activities to plan. The Halifax unit supports residents with dementia. There was an activity programme posted on the notice board but this related to March 2005. The nurse on duty said that residents are offered activities such as board games, videos, exercise activities and picture quizzes. The programme of activities must be updated and reflect the social and leisure activity needs of all residents.
Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 15 The manager told the inspectors that each resident would have an activity recording format in their personal file but no evidence could be found of these activity records. The home must ensure that it clearly evidences the social and leisure activities residents are offered and participate in. The clinical home manager informed the inspectors that Halifax House had implemented a document in relation to the ‘Snoozlen’ room as recommended at the last inspection. During conversations with residents it appeared that they were able to exercise some control over their day-to-day lives. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 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 standard(s) 16 & 18 The home had a complaints procedure that had been given to residents. The home’s policies and procedures required updating to ensure residents are protected from abuse. EVIDENCE: The home had a complaint procedure and residents had been given their own copy. A record was kept of all complaints made and included details of the investigation and any action taken. It was reported by the manager that training on the action to be taken in the event of an allegation of abuse was included in the induction process. This was confirmed when the inspector spoke to a member of staff who had recently completed the induction process. The manager also informed the inspectors that since the last inspection all staff members had received training on abuse awareness by the clinical home manager. The manager had a copy of the Manchester Multi Agency Policy for the Protection of Vulnerable Adults from Abuse. However the BUPA Adult Protection Policy and Procedure makes reference to managers undertaking investigations into incidents or allegations of adult abuse. This does not fit the procedural guidelines set down in the local Multi-Agency Adult Protection Procedures or under ‘No secrets’ guidance. However the manager informed the inspectors that the organisation was in the process of updating the current policies and procedures. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 24 & 26 The building was fit for its intended purpose. However, some areas of the home were not hygienically clean EVIDENCE: The home provides large, attractive, well maintained grounds with a variety of garden areas which are accessible to those residents who are wheelchair bound. Each house is set out in the same way but was individually decorated. Each house consisted of a lounge, dining area, a conservatory, a smoking area and a kitchenette. The home had a programme of routine maintenance and renewal of the fabric and decoration. The standard of hygiene and décor varied between the various houses. The entrance area to Halifax House was found to have a strong smell of urine. The manager acknowledged that this had been noted and new carpets were on order to replace the affected areas.
Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 18 Some of the lounge carpets were found to be heavily stained, in particular the carpet in Shackleton House. Various wheelchairs were dirty and encrusted with food. The nurse in charge of the unit was requested to address the issue. Bedroom 4 on Anson House was found to have cracks in the wall and one wall was found to be dirty and stained. Each of the houses provided 6 WC’s and 4 baths/showers, which were ample to meet the needs of the service users accommodated. Numerous bathrooms were found to have equipment stored in them. For example several hoists, an armchair, a hoover, bed rail bumpers, a housekeepers cleaning trolley and numerous waking frames. The inspectors requested that these were moved immediately. It was disappointing to note that that the requirement made at the last inspection that the chipped and broken tiles in the bathroom numbered 41 on Lancaster House had not been met. In addition the requirement that the leaking shower cubicle in the same bathroom should be fixed and cleaned had not been met. It was noted that the bathrooms on Lancaster House had communal toiletries. This was discussed with the nurse in charge of the house at the time of inspection and she said she would have them removed immediately. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 The numbers and skill mix of staff appeared to be sufficient to meet the needs of the residents. EVIDENCE: The numbers and skill mix of the staff, at the time of inspection appeared to be sufficient to meet the needs of the number of residents accommodated. The home has a format called a ‘Training and Competence Matrix’ for recording when staff had undertaken key training. They had not been completed and so there was no clear record evidencing what training each member of staff had completed. The home must undertake an audit of all the training undertaken by staff. Although there were some examples of staff appraisals that mention the need for certain training, there are no individual training and development plans in place for staff. The home are implementing a BUPA training programme called ‘Personal Best’ that looks at how staff work with residents. The programme has been in operation for 18 months and the manager is acting as coordinator for the programme. Only six staff have started the programme as the Manager said she did not have the time or resources to carry out the programme and perform her managerial duties at the same time. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 20 There was no record of staff that had completed or were undertaking the NVQ Level 2 programme. Staff described how they had been provided with training on the use of a new style of hoist. In addition all the staff were given the opportunity to experience what it is like to be transferred in the hoist. They said that this had helped in developing greater understanding and awareness of what residents experience. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 Not all staff were receiving appropriate supervision. EVIDENCE: The manager informed the inspectors that it was the responsibility of the unit managers to undertake staff supervision. However not all staff were receiving supervision at the time of inspection. Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x 2 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x
COMPLAINTS AND PROTECTION 2 x 2 2 x 2 x 2 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x 2 x x Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 5 Requirement The registered person must ensure all residents are provided with terms and conditions in respect of accommidation to be provided including the amount and method of payment of fees. 1.The registered person must ensure that the home develop and implement an emergency admissin policy. 2. Once the policy has been developed it must be incorported into the Service User Guide and the Statement of Purpose. The registered person must ensure that a record is kept of any nursing provided to the resident, including a reocrd of his/her conditon and any treatment. 1. Residents care plans must be written with sufficient detail to provide clear guidnece to staf of the actions to be taken to meet the residents health and welfare needs. 2. The plans of care and risk assessments must be kept under
Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 24 Timescale for action 31/8/05 2. 5 4 &5 Schedule 1 31/8/05 3. 7 17 Schedule 3 31/8/05 4. 7 15 31/8/05 review. 5. 7 15 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. The use of bed rails must be thoroughly risk assessed prior to their use in order to avoid any unnecessary risks to the health or safety of residents. The use of restraints such as wheelchair lap belts and Kirton chairs msut be risk assessed and consent be obtained for their use. The homes policies and procedures for responding to suspicion or evidence of abuse or neglect must reflect the Department of Health No Secrets guidence. The stained carpet in the lounge in Shackleton House must be thoroughly deep cleaned and if that proves ineffective it must be replaced. No equipment must be stored in any of the residents bathrooms The leaking shower cubicle in bathroom 41 on Lancaster House must be attended to and the cubicle must be thoroughly cleaned. The chipped and broken wall tiles in the bathroom numbered 41 on Lancaster House must be replaced. The sluices must be kept locked when not in use to avoid any unnecessary risks to the health or safety of service users. All wheelchairs must be kept clean and fit for use by
F55 F05 s21656 ringway mews v235630 290605 stage 4.doc 31/8/05 6. 7 13 31/8/05 7. 7 13 31/8/05 8. 18 13 31/8/05 9. 19 23 31/8/05 10. 11. 21 21 13 13 Immediate Immediate 12. 21 13 Immediate 13. 21 13 Immediate 14. 22 12 Immediate
Page 25 Ringway Mews Nursing Home Version 1.40 residents. 15. 16. 17. 24 26 12 23 13 16 The cracks and the dirty wall in 31/8/05 bedroom 4 on Anson House must be attended to. The regsiterd person must Immediate ensure that communal toileteies are not used in home 1. The programme of activities 31/8/05 must be updated and reflect the social, leisure and activity needs of all residents. 2. The home must ensure that it clearly evidences the social and leisure activities residents are offered and participate in. The home must undertake an audit of all the training undertaken by staff. Qualified staff must not take breaks together. The home must ensure that there is at all times a suitability qualified member of staff on duty at all times. 18. 19. 30 27 18 18 31/8/05 31/8/05 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 7 27 28 Good Practice Recommendations It is recommended that residents files contan a recent photograph for easy identification. It is recommended that the staff rotas for all houses include the grades of staff and a key to identify shift times. The home should provide an action plan to evidence that 50 of staff are being trained at NVQ level 2 or equivalent by December 2005 Ringway Mews Nursing Home F55 F05 s21656 ringway mews v235630 290605 stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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