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Inspection on 28/09/05 for The Polegate Nursing Home

Also see our care home review for The Polegate Nursing Home for more information

This inspection was carried out on 28th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. The relatives and representatives are welcomed to the home and are kept informed of any changes and are complimentary about the service provided at The Polegate Care Centre. There is a variety of good nutritious food offered and fresh fruit is readily available. Meals are taken in comfortable and homely surroundings. The home is clean, safe and well maintained, which is appreciated by the residents and their relatives. There is a stable work force of reliable and caring staff, which work well together as a team.

What has improved since the last inspection?

The care plans and risk assessments have improved since the last inspection. The pre-admission assessments were found to be in place and completed in full, which has improved the admission process.

What the care home could do better:

The following are requirements made at this inspection: The resuscitation status mentioned in a care plan needs to be discussed with the G.P and family and then reviewed on a regular basis. That the short stay/respite residents are offered the choice to self medicate before going home to maintain independence and confidence.Those residents that do not have the physical or mental capacity to ring the call bell have an appropriate risk assessment and a plan of action in place to ensure their well-being. That training records are kept up to date, to ensure that the staff have attended the training required to perform their job.

CARE HOMES FOR OLDER PEOPLE The Polegate Nursing Home The Polegate Nursing Home Blackpath Road Polegate Eastbourne East Sussex BN26 5AP Lead Inspector Debbie Calveley Unannounced Inspection 28th September 2005 10:00 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 The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 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. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Polegate Nursing Home Address The Polegate Nursing Home Blackpath Road Polegate Eastbourne East Sussex BN26 5AP 01323-485888 01323-484011 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) ANS Homes Limited Mrs Jacqueline Taylor Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the maximum number of service users to be accommodated is forty-four (44). To care for chronically ill service users under the age of sixty-five (65) years under the continuing care criteria. 20th December 2004 Date of last inspection Brief Description of the Service: The Polegate Nursing Home was purpose built in May 1996 and accommodates up to forty-four service users with continuing care needs under the Health Authority’s eligibility criteria. The home is registered to provide care for service users falling in to the category of older people and those with a physical disability. The home was purpose built to provide single bedrooms with ensuite facilities to heavily dependent service users with a need for continuity of care from hospital. The resident’s accommodation is on two floors; each of these floors is provided with a large lounge. The lower floor has a dining room, which caters for all residents, and most group activities are held in this room. All areas of the home are assessable to service users, the corridors are wide enough to accommodate self-propelled / electric wheelchairs and the lifts are spacious. The rooms are spacious to allow room for hoists and other specialist equipment whilst maintaining a homely and comfortable environment. The décor of the home is pleasant, simple and well maintained and the furniture is of a good quality. There is a garden area with a patio that is accessible to service users in wheelchairs. There are suitable toilet, bathing and washing facilities provided to meet the needs of the service users, all with equipment designed for less abled persons. There are car-parking facilities to the rear of the property for approximately 25 cars. The home is in the centre of Polegate village, close to the shops, railway station and major bus routes The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 28 September 2005. It commenced at 08:30 am and was conducted over 5.5 hours. There were twenty-eight residents living in the home on this day. The methodology of the inspection included a tour of the building, inspection of documentation and records, the delivery of care for eight residents and informal interviews with eight residents, three relatives and six members of staff. What the service does well: What has improved since the last inspection? What they could do better: The following are requirements made at this inspection: The resuscitation status mentioned in a care plan needs to be discussed with the G.P and family and then reviewed on a regular basis. That the short stay/respite residents are offered the choice to self medicate before going home to maintain independence and confidence. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 6 Those residents that do not have the physical or mental capacity to ring the call bell have an appropriate risk assessment and a plan of action in place to ensure their well-being. That training records are kept up to date, to ensure that the staff have attended the training required to perform their job. 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 Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 7 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 The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. A contract/statement of terms and conditions is given to all residents on admission, which confirms the facilities offered and care agreed. A pre-admission assessment is undertaken on all prospective residents before admission to ensure the home can offer them the care they require. The home welcome and encourage prospective residents and their representatives to visit the home prior to admission to enable them to assess the suitability of the home and meet the staff and fellow residents. EVIDENCE: A Statement of Purpose and Service Users guide, which conforms to the Care Homes Regulations and National Minimum standards, is in place. It is available to all residents and their relatives and is written in a clear and user-friendly format. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 9 There have been no changes at this time to the comprehensive statement of terms and conditions, which includes the services covered by the fees and the room to be occupied. It was confirmed from viewing the residents’ files that a pre-admission assessment using the homes own assessment tool is completed on all prospective service users. The assessment takes place at the residents’ place of residence, and input from other relevant professionals is sought when required. It is said that the residents’ representatives are involved if possible. Eight pre-admission assessments were viewed. Three of the residents spoken with were able to confirm that they were visited before admission whilst one could not remember being involved. The pre-admission assessment identifies any specific needs of the prospective resident and this informs the admission process. The documentation available demonstrates that a full assessment of the resident’s specific needs is completed following admission to the home, and then reviewed. Trial visits can be arranged and residents and their representative can spend a day in the home prior to admission. This enables them to meet the staff and other residents, and sample the food and activities. There is a month’s trial either way to ensure that the home is suitable and the home can meet the needs of the resident. Unplanned/ emergency admissions are rare, but if they do occur, assessment and care planning takes place within twenty-four hours. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. All residents have an individual care plan, which meets their health, social and recreational needs. The medication systems in place are well-managed promoting good health and the safety of the residents. The residents are treated with respect and courtesy in all aspects of their care. EVIDENCE: Eight care plans were viewed and were found to be of an improved standard since the last inspection. All were found to have a comprehensive plan of care, which is generated from the initial pre-admission assessment. The care plans clearly identify the specific health, personal and social care needs of the residents. The risk assessments were clear and were seen to have been updated on a regular basis. However there is still a need to continue to try to involve the resident and/or their representative in the formation of the care plan, only one resident spoken with had a knowledge of the care plan and a further two had signatures that The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 11 evidenced involvement from their representative. One relative said she had not been involved, but did speak to the staff on a daily basis. A requirement was made regarding the resuscitation status mentioned in a care plan, this needs to be discussed with the G.P and family and then reviewed on a regular basis. From the documentation available and from case tracking the residents, the health needs of the residents were seen to be met. There was evidence of other professional’s involvement in the care plans, such as physiotherapist, dietician, dentist and optician. The G.P’s visits are also documented. There are policies and procedures in place for the storing, administrating, disposal and receipt of medication. The clinical room on the first floor has been moved to a larger room and is well equipped and more practical for staff to work in. The Medicine Administration charts were viewed and were found completed correctly. The checks of temperature control of the clinical rooms and fridges were available. At the present time, no residents are self-medicating, though it is a requirement that residents that are short stay/respite are offered the choice to self medicate before going home to maintain independence and confidence. First aid boxes are available and were found amply stocked. Throughout the inspection it was observed that residents were treated with dignity and respect by the staff in all aspects of their care. One resident said “it is a marvellous place” another said they are always very nice to me, I don’t feel rushed and they answer my bell with a smile”. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The residents are enabled to exercise the choice and control of their every day life. The activities in the home meet the individual preferences of the residents. The dietary needs of residents are well catered for and offer a balanced and varied selection of food that has been updated in line with the personal likes and choices of residents EVIDENCE: Activities are arranged and take place in the main dining area on the lower floor, the residents were positive in their feedback concerning the range of activities. They were five residents attending activities during the inspection. The routines of daily living are flexible, and residents choose their daily schedule when they are able to, including their meal times and venue. Feedback from the residents and from direct observation on the day, it was apparent that residents are given the opportunity to spend their time as they wish. Two residents said that they did not attend the activity sessions, even though they were asked, they were content to spend time in their room with their books and television. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 13 Residents are facilitated to maintain their independence for as long as they are able. There are no restrictions on visiting times as long as consideration is shown to all the service users. The lounges are available to residents and their visitors for private meetings if their own rooms are not appropriate. Many of the residents have individualised their bedroom with items from home and residents and relatives spoken to confirmed that they are encouraged to make it homely. The home has an advocacy policy in place and the information regarding this is available to all residents. The menus are distributed to all residents and are also on display in the dining rooms. They demonstrated choice and variety and were indicated a well balanced diet. The menus rotate on a four weekly basis and change according to the seasons. Fresh fruit is available; one relative said that the chef had gone out a specially brought some grapefruit for her mother as she had said she liked it. The residents were forthcoming in their views of the food, and the majority said the choice was varied and the food was very good. One resident said, “ the food is very good, almost as good as a hotel”. The dining area are pleasant and well furnished with natural light, it appeared to be underused, as there were only six residents having lunch, but the majority of residents prefer to eat in their room and some heavily dependent residents were seen to be assisted with their lunch in the lounges. The kitchen was not inspected at this time. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. The complaint procedure is clearly detailed in the Statement of Purpose and Services Users guide and is available to residents and their families enabling them to share their concerns formally and confidentially. Staff interviewed had a good understanding and knowledge of Adult Protection policies and procedures, which protect the residents from harm and abuse EVIDENCE: There are appropriate policies and procedures are in place and it was confirmed that these are followed when investigating any concerns raised at the home. One complaint has been received by the CSCI since the last inspection, which is still being investigated by the Registered Manager. The complaint book was viewed and this demonstrated that all complaints are recorded, along with the outcome and action taken by the home to resolve the complaint. The staff interviewed were knowledgeable of the ANS complaint procedure and of how to start the process if the manager is not available. One of the residents referred to the service users guide when asked if they knew how to make a complaint, whilst one resident said he had been given a brochure and was sure he had seen the complaints procedure in it. One resident said she would talk to the nurse in charge if she had a problem. The Adult Protection policy in the home was found to be up to date and staff interviewed were knowledgeable about the systems in place to protect The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 15 vulnerable service users. There is on-going training for all staff in adult Protection. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. There is specialist equipment in the home for residents’ use to maximise their independence. EVIDENCE: There is work on-going at the present time to refurbish and decorate the home. New furniture was being delivered on the day of the inspection. The residents are encouraged and enabled to personalise their rooms with furniture and pictures, and this was evident during the visit. All residents rooms conform to the National Minimum Standards in respect of equipment, such as call bells and furniture. All personal items are listed in the individual care plans. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 17 The accommodation for residents is found on two floors and each of these floors is provided with a large lounge. The lower floor has a dining room, which caters for all residents, and most group activities are held in this room. These communal rooms are non-smoking and residents wishing to smoke do so in their own rooms, following an individual risk assessment. There are suitable toilet, bathing and washing facilities provided to meet the needs of the resident’s, all with equipment designed for disabled and frail people. The home is well equipped with equipment to meet the needs of residents’, and the senior staff are aware of where to procure any specialised equipment. This, in conjunction with the input from the Physiotherapist ensures that needs of the residents are fully met. This multi-disciplinary approach is recorded in the shared care records. It is requirement that all residents that do not have the physical or mental capacity to ring the call have an appropriate risk assessment and a plan of action in place to ensure their well being and safety. There is level access to all areas of the home via a passenger lift. The heating at this home is provided under floor and in the ceiling, this can be controlled in each room by the use of an individual thermostat. The home has a legionella policy in place and all hot water outlets are thermostatically controlled and are tested on a regular basis. Random outlets were tested and were of the required temperature. All risk assessments are updated regularly and the COSHH manual was seen and is available to all staff. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. Some equipment in the sluice areas were found rusty and these need to be replaced. Staff were seen wearing gloves and aprons appropriately. One resident said the “cleaning was very good and they did her room daily”, Another said they took pride in ensuring the home always looked nice and she felt “ very lucky in living in such a nice home”. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staffing levels were adequate to meet the assessed needs of the Residents. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their designated roles. Staff are provided with training pertinent to meeting the needs of the residents and to do their jobs competently. EVIDENCE: Due to the refurbishment and redecorating, the home has sixteen vacancies, however, the staffing levels have remained the same as when they are filled to capacity. This has meant that residents have not been inconvenienced whilst the work has been carried out. It has also meant that the extra interaction between staff and residents has been beneficial and rewarding. Two members of the staff said that it had been really nice to actually be able to spend time talking without feeling that they have to rush. Staff informally interviewed were able to discuss the training they had received whilst working in the home. One carer was able to discuss her training in moving & handling, infection control, fire safety, and also mentioned study sessions on different illnesses that they care for in the home. Staff folders viewed showed evidence of their induction programme, three members of staff said that they felt the induction they had received had prepared them well for the job they were doing. There is on-going enrolling on the NVQ programme and all staff receive encouragement and support to enrol. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 19 Recruitment files were also viewed and were found to have the necessary two references, Criminal Record Checks and employment history. There was evidence of on-going training in moving and handling, infection control, and fire training. A recommendation is to ensure the training records are updated on a regular basis to ensure that they are correct. Staff files also reflected training in POVA, diabetes, continence management and stoma care. The residents spoken with were all complimentary regarding the care they received. A resident said it “was a marvellous place, and he feels so much better now than when he first arrived”. Another said, “They look after me very well”. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36, 37 and 38. There are policies and procedures in place that safeguard residents’ rights and best interests. The environment and working practices of the staff protect and promote the residents health, safety and welfare needs EVIDENCE: The home runs a training programme that is suitable for the staff and for the needs of the residents. Training events are displayed on key notice boards in the home to ensure all staff are aware. As mentioned previously the training folder and staff files were viewed and they evidenced the training undertaken. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 21 Staff supervision has fallen behind at present due to the refurbishment, but will recommence very soon. Staff said that they felt that they were supported and informally supervised on a daily basis, and if they had any concerns or problems that they could approach the manager and senior staff. All records required by regulation for the protection of the service users are in place and accurate. Individual records and home records are kept secure and up to date and are maintained in accordance with the Data Protection Act 1998. All relevant legislation and procedures are in accordance with the standard. Documents and maintenance records are kept up to date and were available for inspection. All staff are kept updated on the Health and Safety policies, the manual is available to all and clearly defined. The staff are issued with certificates yearly for Manual Handling, twice yearly for Fire Safety and Food and Hygiene and all were up to date. There are seven first aiders in the home and the first aid boxes were well stocked. The Accident book for all service users was seen and was correctly completed. Individual risk assessments for cot sides are in place. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 18 3 3 3 3 3 3 3 3 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 X X X X X 3 3 3 The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 23 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 OP7 Regulation 15 (1) (a) (b) (c) Requirement The resuscitation status mentioned in a care plan needs to be discussed with the G.P and family and then reviewed on a regular basis. That the short stay/respite residents are offered the choice to self medicate before going home to maintain independence and confidence. That residents that do not have the physical or mental capacity to ring the call bell have an appropriate risk assessment in place and a plan of action in place to ensure their well being. That training records are kept up to date, to ensure that the staff have attended the training required to perform their job. Timescale for action 28/11/05 2 OP9 14 (1) 28/10/05 3 OP38OP22 13 (4) (c) 28/10/05 4 OP30 18 (c) (i) (ii) 28/10/05 The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations That all rusty equipment be replaced. The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Polegate Nursing Home DS0000014027.V253052.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!