CARE HOMES FOR OLDER PEOPLE
Safe Harbour Nursing Home Abbots Drive Bebington Wirral CH63 3BW Lead Inspector
Sylvia Brown Key Unannounced Inspection 2nd July 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Safe Harbour Nursing Home DS0000039379.V335513.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. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Safe Harbour Nursing Home Address Abbots Drive Bebington Wirral CH63 3BW 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) 0151 643 1591 francesblackburn@onetel.com Dr A Kumar Shyama Singh Frances Blackburne Care Home 45 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (20) of places Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Two (2) named female adults under 65 years of age. One (1) named male adult under 65 years of age. Two (2) named service users in category DE (E). One named adult under the age of 65 in the category of OP (N) Date of last inspection 30th August 2006 Brief Description of the Service: Safe Harbour is a modern, purpose built care home. It is located in a residential area close to shops and other local amenities. It is registered to accommodate 20 elderly persons who require nursing care and 25 elderly persons with dementia who require nursing care. The home is on two floors with bedrooms, lounges and dining rooms on both floors. A passenger lift provides full access to all areas of the home. The home provides both single and shared rooms and some rooms are provided with en-suite facilities. Fees range from to £485.92 depending upon the level of service required. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The key unannounced inspection visit of Safe Harbour was completed in one day. A key inspection looks specifically at all the key National Minimum Standards and evaluates what the home is doing to meet them. Other standards were also looked at. Prior to the inspection the manager completed a pre-inspection questionnaire that detailed some of the actions to ensure the safety of people who use the service and is one of the ways the CSCI gathers information about the home. During the site visit time was spent observing staff as they went about supporting people who use the service. Mealtimes on both floors were observed. The building was inspected as was a number of records which related to the health and safety of people and the running of the home. The care of two people was looked at in depth. Comment cards were provided to people who use the service, their family and professional visitors. Information received will be included within the report where appropriate and applicable. Comments received after the report is completed will be included within the next inspection process. What the service does well:
Safe Harbour continues to offer people who use the service a good quality service which is personalised and caring. The upgrading of the home continues, this is to ensure that people who use the service have live in a homely well maintained surroundings. During the inspection visit it was evident that the manager and staff understand the needs of and cares for those with a dementia and or mental health type illness very well. Without exception, relatives commented positively on the care of those living in the home and of the support they receive. When asked what was good the following comments were made. “I feel the health care , nourishment and attention to the well being and ill being is what they do well. They communicate with families and genuinely care for the residents. Relatives are always made to feel welcome.” “There is genuine care from them to do their best for the residents even by the less skilled staff. The head nurse on EMI unit is efficient, caring and always keeps the family fully informed.” Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 6 “Not only do staff treat residents as individual characters with their individual likes and dislikes, they are most welcoming to families, giving their care and support at all times.” “The nurses are there if we need to talk and the carers are very good to myself and our family”’ “The staff are particularly good and very loving and supportive.” Such consistent positive comments demonstrate that the manager and staff are dedicated to providing an all inclusive service including involving families and friend of people who use the service . The registered manager stated that she believes that the home is aware of the importance of supporting families to come to terms with their relatives illnesses and receive reassurance that they are still a part of their loved ones lives. The staff records confirmed that they had been trained in meeting the care needs of people who use the service who have dementia and mental ill health. This showed that the staff team were sufficiently skilled to meet the everyday needs of people who use the service , which in turn meant that peoples health and welfare was safeguarded. All who use the service had well detailed care plans in place which explicitly recorded their individual needs, how they should be met, by whom and how often. What has improved since the last inspection?
The building continues to be upgraded. The manager has improved the manner in which it records wound care support ensuring it is more accurately documented. Action has been taken to ensure that activities are routinely planned for and that an activities co-ordinator has designated hours to provide the support required. However, there is still issues regarding the success of the activities plan, and if it is sufficient to actually meet the needs of the numbers of people accommodated. A complaints record has been put into place which clearly demonstrates complaints, the actions taken to investigate, and the outcomes provided to the complainant. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 7 What they could do better:
Whilst it is evident that the manager and staff do in the main succeed in providing a good standard of care, there are some areas which need reviewing and further development to ensure standards are maintained in all areas. Individual records did not demonstrate that people who use the service received sufficient support to socialise or join in activities as they desire. There were significant gaps in records indicating that some people may have not known about activities or been invited to join in or receive individual support. The activities co-ordinator stated this was not a true reflection of the social support offered at the home, rather it was a lapse in recording by both himself and other staff when they undertook activities. In order to evaluate that the home provides sufficient social opportunities records should clearly records people’s individual involvement and participation. It was unclear how care staff supported the homes activities programme. Currently the hours designated to the activities co-ordinator do not appear sufficient to providing individuals with the support they require. A review of the activities service is recommended to ensure that sufficient social interaction is provided and that people who use the service receive the benefits from social involvement. Mealtime routines were not reflective of the homes good standards. Not all people who use the service had the opportunity to receive their meals at a dining table. Tables were not laid to promote independence. People’s dignity was compromised by the routine provision of large aprons, and staff talked with each other when providing one to one support to people at mealtimes. Practice could also be developed to ensure that people who use the service have the opportunity to have choice and food portions to suit their needs and preferences on any given day. Meals should be served are at the correct temperature. The development of mealtime practices should promote and encourage people who use the service to have enjoyable and pleasant mealtime experiences. Required records, such as regulation visits should be on the premises and available for inspection. This will enable the home to evidence compliance with regulation 26. In order to comply with the data Protection Act, completed records should be filed in the individual’s personal file. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 8 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. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 5 Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people who use the service have their needs assessed, receive appropriate information and are able to visits prior to making any decisions about moving into the home. EVIDENCE: The inspection of two peoples file confirmed that they had their needs assed by the manager and had been able to look around the home before making any decisions about moving in. The registered manager stated that moving in programmes are individualised to suite the needs of each person. Comment cards returned by people who use the service identified that they were provided with sufficient information which enabled them to make informed decisions about moving into the home. Safe Harbour Nursing Home DS0000039379.V335513.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. People who use the service have their health care needs recognised and met. EVIDENCE: People who use the service have their care needs assessed and recorded within individual care plans which are kept under review. Records clearly evidenced that health care professionals visited the home and that routine health care checks were carried out. Good medication management procedures are in place. Medication administration records were well maintained and recorded that prescribed medication was administered as prescribed. With the exception of mealtimes, staff were observed treating people who use the service with dignity and respect. Preferred names of people were known and used. Positive relationships and friendships were evident between people and staff. Relatives comment cards confirmed that they felt the home supported their loved ones very well and that they we made to feel included
Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 12 and were informed of any changes to their relative health and or condition. One stated “I am always consulted and kept informed of dad’s care, treatment and health issues”. For further information about mealtime please refer to standard 15. Safe Harbour Nursing Home DS0000039379.V335513.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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunities to join in daily activities. They receive a varied balanced diet. All people who use the service should be offered the opportunity to sit at a dining table at meal times, have their independence promoted, be afforded dignity and respect when dining. EVIDENCE: As stated within the summary, the home employs a part time activities coordinator, who ensures that an activities programme is planed for and provided to people who use the service. Posters around the home signified that activities were planned for most days and that service users were invited to attend activities on other floors. Care files identified people’s individual preferences for social activities, interests and hobbies. An evaluation of the two people case tracked identified that infrequent activities were recorded. From looking at other records it was
Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 14 unclear if this was actually true or that the activities co-ordinator and or other staff had not completed the records appropriately. Some records did indicate one to one time being spent with people, and it was positive to see that the activities co-ordinator had sat with a service users in their room offering conversation and company whilst they watch television. People receive visitors as they wish and the homes visitors record was maintained appropriately. The home prides itself that it affords people who use the service with dignity and respect and promotes their individuality and encourage choice. Unfortunately routines around mealtimes were not reflective of that standard. Routines for providing service users with meals appeared to be somewhat institutionalised. A number of people on the top floor remained in the lounge for their meals. It is recognised that the dining area will not seat all service users in one sitting. Consideration is being given to extending the dining space in the future, however it is not known why the current mealtimes have not been adapted to have more that one sitting, enabling people who use the service to have the opportunity to move and receive their meal at a dining table. Also it appeared that meals were brought up to the top floor ready plated. This prevented consultation with people about what food items they preferred and of the size of their meal, furthermore the sweet served was not sufficiently heated and was served cool. People’s independence and choice was restricted and respect and dignity compromised. People were not able to pour drinks for themselves and /or others. Dining tables were not set with glasses and no juice was readily available. It was also unclear why the staff did not pour peoples tea when it arrived on the top floor. Rather they waited until all people had received their meal before providing a drink. Material aprons were placed on many people who use the service, where it was evident that large serviettes would have provided sufficient protection and promoted the dignity of those who required such items. The manner in which staff served sandwiches was not appropriate in that staff handles them when serving. Furthermore there was no salad offered, dressing or crisp etc to make the meal more pleasurable. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 15 Observations were that whilst staff assisted feeding people they carried on conversations with each other, often turning away from people they were assisting to talk with others. When asked within comment cards about meals one person stated that there was a lack of ‘real butter’ and that they would like ‘additional milk with their porridge.’ Another stated “Lunch is usually very good and the soup served at every meal is nice”. Notwithstanding these comments, on the day of the inspection visit there appeared to be a general air of disinterest about meals and mealtimes both by people who use the service and staff. The registered manager was informed of the observations made. When talking with the cook it was apparent that she had met with all the service users and was aware of their individual needs. She appeared dedicated to ensuring that individuals received the food they likes and was open to ways in which meals and mealtimes could be developed. Discussions were held regarding the provision of home made cakes and treats, which can be adapted to have increase calorific value for those where weight loss is apparent and or be made suitable to those on a diabetic diet. Such practice would increase the choice for such individuals. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. People who use the service knew of the homes complaints procedure and felt confident that their complaints would be taken seriously and acted upon. They are protected from harm by the adult protection procedures and by staff who have received adult protection training. EVIDENCE: There are both complaint and adult protection procedures in place. The comment cards completed by people who use the service indicated that they knew how to make a complaint and that they had someone to talk to if they had any concerns. When asked if they knew how to make a complaint relatives commented “I would speak to the matron as she is always there” and “if we have raised issues they have always been dealt with correctly.” The complaint record had recorded two complaints in detail. There was good information about the actions of the manager to investigate and inform the complainant of the outcome. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 17 Staff training records training records confirmed that adult protection training was ongoing and had for some receive training and or updated training in 2007. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service live in a home which offers comfort and safety and is equipped with aids and adaptations to meet their needs. EVIDENCE: Since taking over ownership in 2003, the registered provider has continued to upgrade all parts of the home. As part of the inspection process the registered manager provided the CSCI with the homes maintenance and upgrading programme from 2004 to predicted and planned for work into 2008. At the time of the inspection visit a number of storage areas had been removed and new areas for storage created. It is the intention of the home to further improve the home by provision of new bathing and showering areas and the creation of a hairdressing room. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 19 The old windows are in the process of being replaced by new double glazing units which enhance the appearance of the building. Some windows needed blinds or curtaining to promote privacy and a homely environment. The top floor is designated for those who have dementia and or mental health type issues. The home has consulted with appropriate professionals regarding decoration and have provided tactile wall decoration which stimulates memory and activity. Picture notices are also displayed which support service users understanding to time and place. Bedrooms looked at were personalised and presented nicely. New carpets have been fitted in bedrooms and redecoration completed in many areas. Lounges have been redecorated and were suitable places for people to spend their day when sitting with others. Plans for remainder of year include the upgrading of the bathrooms both upstairs and downstairs. Consideration is being given to extending the top floor to provide larger dining space and additional bedrooms. It is the intention of the manager fit patio doors within the home and continue with the upgrading of the garden to include raised flowerbeds. Safe Harbour is equipped with appropriate aids and adaptations ranging from individual specialised equipment and general items such as handrails, hoists and assisted bathrooms. A call system available in rooms and all areas of the home. Trained records identified that appropriate personnel have been trained in health and safety and joinery and general maintenance, which ensures as far as possible that the home is maintained in a safe manner for people who use the service. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are appropriately recruited trained and competent and in sufficient numbers to support people who use the service. EVIDENCE: The training plan detailed that training had been completed in wound care and accountability, leg ulcer training, catheter management, diabetes, first aid, dementia awareness, challenging behaviour, infection control, adult protection and many more topics relating to the care and promotion of health and safety of people who use the service. This evidences the commitment to having trained and competent staff at all levels supporting people and ensures standards of care practice are maintained to a good standard. Many of the courses are to be repeated during 2007 and early 2008. Staff files looked at confirmed that training had taken place. Files also confirmed that the manager operates a robust recruitment and selection procedure. Applicants complete application forms, attend for interview and have statutory checks completed on them before they are employed. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 21 The duty rota indicate the staffing levels on each floor. Staff are employed and deployed in appropriate numbers to support the needs of people including escort duties for health care appointments. The manager provides student nurses with learning opportunities. Students are under continued monitoring from registered nurses on duty and their tutor, who was on the premises at the time of the inspection visit. The PIQ identifies that 62 of staff are trained at NVQ level 2 or above which exceeds the current standard of 50 . Twelve care staff are trained in first aid as well has having registered nurses on duty on each floor at all times. The relationship between the residents and staff was observed as very positive. Service users comment cards confirmed they felt staff always listen to them and act on what they say and are always available when needed. Seven relatives stated that care staff usually had the right skills and experience to look after people who use the service. Each person accommodated has assigned to them a registered nurse and a named keywoker. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service live in a well managed home which ensures as far as possible their health, safety, comfort and enjoyment. EVIDENCE: There have been no changes in the management structure at the home The manager, and the care manager, are both qualified nurses and have gained an NVQ in management at level 4.The registered manager has a strong leadership style and ensures her standards for delivering a quality service are known. Records relating to health and safety and the management of the home were looked at. Servicing records and safety checks were appropriately undertaken Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 23 with certificates of compliance and suitability evident. There are ongoing auditing systems which evaluate monthly various aspects of the home. The registered manager confirmed that regulation 26 visits were conducted as required. However up to date records of those visits were not on the premises at the time of the inspection. Accident records are completed and are also audited. In order to fully comply with the Data Protection Act, records should be files in the individual persons care records. Small balances of money are managed for a few people who use the service. They are able to have money as they wish through banking systems within the home and company. An administrator external from the home ensures that accounts are audited and that receipts are obtained to confirm expenditure. Routine purchases of magazines, papers and hairdressing etc are made for many people who are then later billed for their individual expenditures. Relative are invited to relatives meetings and are able to contribute to the running and development of the home. The views of residents and their families are gathered from one to one discussions and at meetings held with family members. A full quality assurance audit which seeks the views of people who use the service, relative, visitors, staff and other stake holders have not been completed in accordance with regulation 24 and standard 33. The home gained the Investors in People accreditation in September 2006 Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 X 3 3 STAFFING Standard No Score 27 3 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 2 X 3 X X 3 Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP10 OP14 OP12 Good Practice Recommendations The manager should ensure that staffs practice, conduct and systems within the home promote the dignity and respect to people who use the service at all times. A review of the systems to provide social opportunities and activities for people who use the service should be reviewed. Where required the system in place should be developed to demonstrate practice and ensure it is being completed in the manner expected by the registered manager A review of mealtime practices should be undertaken with the aim to ensuring that all people who use the service are offered opportunity to sit at a dining table, have their independence promoted and have mealtimes which are pleasant and enjoyable experiences. A quality assurance audit should be completed which ensures that people who use the service, family professional visitors and other interested parties are
DS0000039379.V335513.R01.S.doc Version 5.2 Page 26 3 OP15 4 OP33 Safe Harbour Nursing Home 5 OP38 consulted about services. A report of the outcome should be made public a copy of which is supplied to the CSCI. Ensure all records are maintained in accordance with the data protection act. Information held on people who use the service should not be collectively stored. Safe Harbour Nursing Home DS0000039379.V335513.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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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