CARE HOMES FOR OLDER PEOPLE
Ringway Mews Nursing Home Stancliffe Road Sharston, Wythenshawe Manchester M22 4RY Lead Inspector
Geraldine Blow Unannounced Inspection 08:45 5th June 2007 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.V337523.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. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 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.V337523.R01.S.doc Version 5.2 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 28th November 2006 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, one of the houses that provided nursing care was currently 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. The charges for fees range from £375 to £585 per week. There are additional charges for magazines, papers, hairdressing and Chiropody. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 28 November 2006 and supporting information received in the Pre Inspection Questionnaire submitted by the manager prior to this visit. No resident comment cards were received by CSCI. This unannounced visit forms part of the overall inspection process and was conducted by 2 inspectors and the pharmacy inspector. The visit took place on Tuesday 5 June 2007. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This inspection was also used to decide how often the home needs to be visited to make sure that it meets the required standards. As part of the visit time was spent examining relevant documents and files, talking with the home’s manager, the unit manager, several people living at the home and some members of staff. A tour of Halifax House, which provides care for people with Dementia, was also undertaken. During this visit two hours was spent observing the interactions between staff and residents in the communal area of Halifax House to give an insight into the general state of wellbeing of residents. This was done by the inspector sitting in the lounge/dining area and recording staff interactions with three of the residents and then examining relevant records of the three residents. What the service does well:
Halifax House provided a clean and pleasant environment for the residents who live there and there is a safe enclosed garden for residents to use. A pre admission assessment of needs is carried out before a resident is admitted to the home to make sure that the home can meet all their needs. The menus seen indicated that a wholesome, varied diet was provided and on the day of this visit residents were seen to be enjoying a full cooked breakfast and a choice of meals were provide at lunchtime. Residents were seen to be given a choice of food and drinks and extra food or snacks were given on request. During both meal times staff were seen assisting residents who required help to eat their meal, in a sensitive, unhurried manner. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 6 During a 2-hour observation period, on Halifax House, staff were seen to speak to residents in a respectful way. Staff were caring in their approach and created a relaxed atmosphere, allowing residents to do what they chose to rather than staff deciding for them. Independence was encouraged and residents were seen freely moving around the home, while discretely being observed by staff. Residents were encouraged and supported to maintain contact with family and friends and e-mail was used to keep families not living in this country up to date on their relatives’ day to day lives. Systems were in place to support residents or visitors to make a complaint and the manager thoroughly investigated complaints and kept accurate records. A variety of activities are provided at the home and on the day of this visit a evening birthday party was arranged for one of the residents and an afternoon in the garden doing karaoke and having a shandy. The home encouraged staff training to ensure that they had the necessary skills to meet the needs of the residents accommodated and carried out a robust recruitment procedure to ensure the staff employed are safe to work with residents. What has improved since the last inspection?
Since the last inspection the manager, the unit manger and all the nursing staff have worked hard to improve the way the medication is handled. Medication is now recorded and administered well and residents are safe when they are given their medicines. Further improvements have been made to residents individual plans of care. The care files were well organised, well maintained and divided into relevant sections, which made them easy for staff to use daily as a working tool. The plans of care were found to be detailed, informative and clearly set out the action that needed to be taken by staff to ensure that the health and personal care needs of the residents are met. All recommendations made at the last inspection visit had been met. Since the last inspection the pre admission assessment document has been updated to include if the prospective resident requires an independent advocate under the Mental Capacity Act. This shows that the home are taking into account the implications for its residents of the new legislation regarding people’s capacity and ability to make their own decisions. The home has introduced a more flexible way residents can have something to eat when they want. The home call this ‘Night Bites’ and means that light
Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 7 snacks are available on the separate units and residents have access to a picture menu and ask staff for these snacks at any time of the day or night. Also, the manager has a monthly nutritional meeting to look at all food related issues and this includes monitoring of residents weights to make sure there has not been any rapid loss or increase that could impact on their health. These are both seen as good practice. 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 3 (Standard 6 intermediate care is not provided at Ringway Mews Nursing Home). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make a decision about the home and their needs are assessed prior to them being admitted to the home to ensure that their needs can be met. EVIDENCE: As identified in the last report BUPA has a standard information pack that includes general information regarding BUPA Homes and a Statement of Purpose that was specific to Ringway Mews. The manager said that all prospective residents or their representatives are given the pack and then on admission to the home residents are given a welcome pack, which includes a Service User Guide (SUG). Since the last inspection the manager sends 2 copies of the SUG and asks for one copy to be signed and returned to show that the prospective resident/relative has read information about the home to enable them to make an informed choice.
Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 10 A documented pre admission assessment form is in use to ensure that prospective residents are only admitted on the basis of a full assessment and evidence was seen that for residents who are referred through Care Management arrangements the manager obtains a summary of the Care Management Assessment. The pre-admission assessment now includes reference as to whether the prospective resident requires an independent advocate under the Mental Capacity Act. This shows that the home are taking into account the implications for its residents of the new legislation regarding people’s capacity and ability to make their own decisions. This is seen as good practice. An intermediate care service is not provided at Ringway Mews. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health care needs had been identified and systems were in place to meet their needs. EVIDENCE: Three residents were case tracked on Halifax House. These three residents were observed over a 2-hour period and then their care plans and Medication Administration Records (MARs) were examined. The observations were followed up by discussion with the manager and the unit manager. As already stated in this report the observations were very positive and the residents appeared happy and content. Staff were seen to encourage independence, choice and maintain the dignity of the residents. During the observation period of the three residents and general observations of all residents in the communal area staff were seen responding to residents requests and needs and were seen having group discussions as well as one to one interactions.
Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 12 The care planning process was much improved since the last inspection visit. They were easy to use and contained appropriate assessments and detailed care plans of how to meet the health and personal care needs of residents. The care plans were found to be person centred and had been regularly reviewed to reflect any changes in care needs. An initial care plan is generated within 72 hours of the resident’s arrival and the deputy manager reviews the care plan after 72 hours to make sure all the information has been recorded. The care plans are then monitored every month to make sure they have been evaluated by the nurse. Residents who have been assessed as requiring funded nursing care have their nursing needs reviewed every 3 to 6 months and the purchasing local authority undertakes an annual review of the care package. A formal in-house review is undertaken every 6 months every six months. The resident and their representatives/family are invited to attend and this involvement is recorded in the residents file. The manger monitors these review on a regular basis. To ensure that the home can continue to meet resident’s needs all residents who return from a hospital stay are reviewed and their nursing needs reassessed. There was only one concern regarding medication in that on the day of inspection one resident had run out of a prescribed medicine some 2 days earlier and it was also noted a new resident had been without one of their prescribed medicine for six days. Not having sufficient supplies of medication could put residents health at risk. However there were significant improvements in all other areas of medicines handling and it is recognised that everyone involved in medicines administration have worked hard to make sure that residents are given their medicines safely. Since the last inspection the managers have put in place systems to make sure that all areas of medication handling are safe. There are good systems in place to make sure that medication records are accurate and that they show that residents are given the correct doses of their medicines. The records also show that all medicines including creams, inhalers and dietary supplements are accounted for and do not go missing. During the inspection the pharmacist inspector looked at the records and medicines on one unit and for 3 residents in detail. It was found that all medication was administered exactly as prescribed by the doctor, which is good for the residents’ health. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to exercise control over their day-to-day lives and activities were provided. EVIDENCE: The care plan documentation included a life history and a map of life in an attempt to obtain information regarding residents’ former interests and hobbies. Activity coordinators are employed and have a have a weekly activity plan for each unit. The coordinators are maintaining a separate record of their involvement with each resident and the activities they take part in. The activity coordinators spend time with new residents to find out what their interests are and what activities they enjoy. They do not record any of this. It is recommended that the activity coordinators evidence in writing the work they do with residents to find out what activities they enjoy. This information can then be used to update and improve residents care plans.
Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 14 The activity coordinators are involved in the Induction programme for new and existing staff to emphasis the importance of activities and the role staff play in supporting residents to take part. This is seen as good practice. There is an open visiting policy and it was evident from speaking to staff that residents are encouraged and supported to maintain contact with their families and friends. From observations during the inspection residents were encouraged to exercise choice and control over their lives and staff took the time to ask residents questions rather than making a decision for them and residents were allowed to be active or could sit quietly if they wished. The menu offered a variety of wholesome and nutritious meals. A choice of meals was offered and snacks and drinks were given on request. Staff were seen offering assistance to residents, were required, in an appropriate and sensitive manner. As already mentioned in this report the ‘Night Bites’ system and the monthly nutritional meetings are seen as good practice. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home encouraged and supported people to raise their concerns and complaints and had the policies, procedures and systems in place to protect residents from abuse. EVIDENCE: Since the previous inspection the home have received 4 formal complaints and 6 informal concerns. A record of the complaint/concerns is maintained for each issue and the actions taken are recorded. Policies and procedures relating to Adult Protection are available in the manager’s office and on each unit. If a resident’s behaviour gives cause for concern then the relevant nurse will undertake a risk assessment around the issue causing concern and provide written guidance on how to keep residents safe. Staff continue to complete incident forms of anything that affects residents safety. Since the last inspection the home have been involved in one Protection of Vulnerable Adult (POVA) investigation. The manager has responded to the lead local authority for any requests for information and all recommendations made as a result of the investigation have been implemented. It is recommended that a written record of the time-line of events/actions be maintained to record the full involvement of the home’s management and staff in a POVA investigation.
Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A clean, comfortable, well maintained environment was provided for residents. EVIDENCE: The accommodation is well furnished and is suitable for the residents living there. On the day of this visit the home was odour free and was found to be clean and tidy which created a pleasant environment for the residents and their visitors. Each house has its own garden area that is accessible to residents and many of the bedrooms were seen to be personalised. The laundry was situated away from residents living and eating areas. Soiled linen did not come into contact with food storage, preparation, cooking, serving or dining areas. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 17 The home provided adequate toilet and bathroom facilities. Toilets were conveniently located in close proximity to bedrooms and communal areas. A variety of bathing facilities were provided to meet a range of needs. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment and selection process protected residents from potential abuse. EVIDENCE: On the day of this visit and from examining staff rotas the numbers and skill mix of staff appeared to be sufficient to meet the needs of the residents accommodated. The pre inspection questionnaire stated that the home employed 58 care staff, 13 of which had achieved NVQ level 2 or above and 17 care staff are currently undertaking NVQ Level 2 training. Three staff files were examined. The staff had all started work since the last inspection. It was found in all 3 cases the home had used the POVA First system to allow staff to begin working before receiving a CRB certificate. Even though the new staff do work alongside experienced staff until they complete the three day induction the home were using the POVA First system for all newly appointed staff rather than following the Department of Health guidelines.
Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 19 The staff files contained the other relevant documentation and records such as application forms, references and identification documentation. The Induction Programme for new staff consists of a three-day event that includes the key components of the Skills for Care Induction modules. Each member of staff then has to complete an induction workbook called a ‘Care Portfolio’ which is based on the Skills for Care Induction modules and requires the member of staff to answer set questions and to demonstrate their understanding. Each new member of staff has a named mentor who is responsible for ensuring the portfolio is completed and in deciding that the member of staff has shown competence in that area of work. After 12 weeks the programme should be completed and the portfolio is reviewed by the training manager and signed by them and the manager to state that the member of staff is competent. In addition to the portfolio, members of staff are given workbooks in the areas of moving and handling, food hygiene, health and safety and activities that they complete. The Training Manager spends time with all the members of staff to talk about their training and development needs and to agree an action plan for meeting those needs. From this each member of staff has a training and development plan. A training matrix has been developed that records all training undertaken by members of staff and identifies gaps in training need and when refresher training is required. Evidence was seen that members of staff had attended needs specific training such as dementia care and challenging behaviour. A monitoring system had been developed where a month after the training the Training Manager would talk to the member of staff to find out how they were putting the skills learnt into practice and so determine whether they were competent in that area. To ensure the safety of the residents Protection of Vulnerable Adult Training (POVA) is provided for all staff. However it is recommended that the training be reviewed to make that staff are clear about exactly what their individual role is in protecting residents from harm. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interest of residents who live there. EVIDENCE: The staff and residents accommodated benefit from a committed, caring manager who is a qualified nurse and has a wide range of nursing experience. She demonstrated a clear view of the need to continually develop the care service in the best interests of the residents and the necessity of continued staff support. There is a clear and transparent system for managing and recording the personal finances of those people who they previously had responsibility for
Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 21 being the appointee. The system in place is that either the resident, their family/representative or the relevant local authority is responsible for their personal finances. All transactions and documentation was regularly audited by the admistrator, the manager and through the main organisation (BUPA). Evidence provided in the Pre Inspection Questionnaire demonstrated that the health, safety and welfare of the residents and staff are protected. BUPA continue to undertake a quality survey of the service being provided, analyse the results and produce a report based on the findings. The last report produced was dated December 2006 and the report was shared and discussed at the last quarterly resident/relative meeting. In addition to the formal tool and the quarterly meetings feedback regarding the quality of care provided is discussed with residents and their relatives during their review sessions, which are undertaken as a minimum every 6 months. In addition the staff regularly have discussions with residents and their visitors on an individual basis and the manager encourages comments and feedback via her open door policy. Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 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 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 N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ringway Mews Nursing Home DS0000021656.V337523.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No No 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 OP9 Regulation 13 (2) Requirement All residents must have an adequate supply of medicines to ensure continuity of treatment. Timescale for action 05/06/07 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 OP12 OP18 Good Practice Recommendations It is recommended that the activity coordinators evidence in writing the work they do with residents to find out what activities they enjoy. It is recommended that a written record of the time-line of events/actions is maintained to record the full involvement of the home’s management and staff in a POVA investigation. The DOH guidelines for using the POVA First system should be applied when employing new staff without first having gained a relevant CRB. It is recommended that the POVA training be reviewed to ensure that it clearly reflects the different roles and responsibilities of the staff and management in protecting residents from harm.
DS0000021656.V337523.R01.S.doc Version 5.2 Page 24 3. 4. OP29 OP30 Ringway Mews Nursing Home Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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