Inspection on 03/05/07 for The Shrubbery

This inspection was carried out on 3rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Shrubbery 11/09/08

The Shrubbery 10/10/07

The Shrubbery 12/05/06

The Shrubbery 11/10/05

The Shrubbery 05/05/05

The Shrubbery 19/11/04

The Shrubbery 13/05/04

The Shrubbery 03/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Shrubbery 66 College Street Higham Ferrers Northants NN10 8DZ Lead Inspector Judith Roan Key Unannounced Inspection 3rd May 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 The Shrubbery DS0000012910.V336044.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. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Shrubbery Address 66 College Street Higham Ferrers Northants NN10 8DZ 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) 01933 317380 01933 317380 claire@rochmills.co.uk Rochmills Limited Natalia Emilia Mychajlyszyn Care Home 45 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (31), Physical disability over 65 of places years of age (6) The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Shrubbery care home is registered to provide personal care for male and female service users whose primary needs fall within the following categories: Old age, not falling within any other category (OP) 18 Dementia - over the age of 65 years DE(E) 8 Physical disability - over the age of 65 years PD(E) 6 Mental disorder - excluding learning disability and dementia - over the age of 65 years MD(E) 13 Service users accommodated within the MD(E) category should only be admitted to the Churchill Wing of The Shrubbery. The maximum number of persons to be accommodated at The Shrubbery is 45. 21st September 2006 2. 3. Date of last inspection Brief Description of the Service: The Shrubbery is a care home in Higham Ferrers. There are local facilities and amenities including shops and there are public transport links to the neighbouring towns of Rushden and Wellingborough. The home provides personal care for up to 45 people over the age of 65 years; within this they are registered to provide care for up to 8 residents who have dementia or a history of mental health and 6 with a physical disability. Fees range from £324.16 to £410 according to the level of care required. Accommodation is provided over two floors with a passenger lift and staircase for access to the first floor bedrooms. On the ground floor there are several communal rooms including two dining rooms, three lounge areas and a conservatory. There are gardens and level access to the main entrance with ample car parking for visitors. There are 33 single rooms of which 29 have ensuite facilities and 6 double rooms with 3 of these being ensuite. Information about the home can be found in their Statement of Purpose and Service User Guide. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Service Users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 3 service users and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The inspection took place during the late morning and afternoon and following morning, over a period of 8.5 hours and was carried out on an unannounced basis. The provider completed a pre inspection questionnaire and surveys were received from residents and families. This report also includes summaries from the random inspection on 21st September 2006 undertaken to monitor compliance of requirements made at the last key inspection. What the service does well: What has improved since the last inspection? What they could do better: Care plans remain poor and do not direct staff in meeting resident needs in full. For example the metal health needs of one resident are not clearly stated placing other residents at risk. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 6 Menu choices are limited as ordered provision fail to be purchased. The menu does not meet the needs of resident’s that are diabetic. The third bathroom requires redecoration. Evidence of resident or their advocate being involved in planning and reviewing care, needs to be evident and would demonstrate good practice. Residents with a diagnosis of dementia should have care plans in place to address their mental health needs. These plans should focus on their strengths as well as weaknesses. Environmental adaptations should be available to meet the needs of those residents with a diagnosis of dementia. Healthcare needs should be clearly recorded within care plans and clearly demonstrate how these are met. It is recommended that residents with a diagnosis of dementia should be cared for in a dedicated area of the home in order that both their specialist needs and the needs of other resident groups may be met. Covert medication needs to be approved by a multidisciplinary healthcare team. Medication profiles need to give the reason for prescribed medication and instruct staff on dealing with problems arising from side effects. Activities need to be based on individual personal preferences, social histories and be person centred. Residents who do not have the mental capacity to make informed decisions need to be protected by an independent advocate working on their behalf. The problem of excessive heat in the conservatory should be addressed. Management structures within the organisation need to delegate sufficient responsibilities to enable the Registered Manager to fulfil their role. Evidence should be available that carers receive formal supervision at least six times a year. 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. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 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 Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Standard 6 does not apply to the home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents cannot be assured that their needs will be fully assessed prior to admission. EVIDENCE: The needs of prospective residents are generally assessed prior to admission. It is important that full medical details and social histories are recorded prior to admission. Information about the home is provided within the homes Statement of purpose and service users guide and these are available to all residents and or their representatives. The resident’s files contained full details of assessed needs that enable carers to provide the service. An application to vary the categories of resident that the home can provide for was completed last year to extend the provision of service to meet the needs of older people with mental healthcare needs. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 9 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 poor. This judgement has been made using available evidence including a visit to this service. Residents care plans do not contain all the relevant information to instruct carers to meet their needs. EVIDENCE: Assessment of need in one residents file was poorly completed which led to a poor care plan being developed. Care plans on the other resident’s files were limited and there is evidence that little improvement has been made in this area since the last key inspection and a random inspection to monitor compliance last year. There was also no evidence that residents had been involved with the development of plans. The care of resident’s living at the home was adequate and needs were generally met. Issues arise in an afternoon where staffing levels are lower and at mealtimes there is insufficient support available. This is particularly evident during the late afternoon due to staffing levels being diminished when one carer prepares tea. The requirement made at the last inspection therefore remains and is restated. A further requirement is made under staffing to ensure care needs are met The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 10 One residents care plan did not indicate how they were to be supported with their mental healthcare needs and it was evident that staff were ill equipped and trained to meet their needs. Risk assessments were limited in directing staff on how they manage behaviour that placed others at risk. The manager had given notice to the Social Services that they were not able to meet their needs. The file also failed to contain information of the resident’s status on discharge from Hospital and in discussion with the Registered Manager this was not clarified. A requirement is made to ensure that a full history is taken prior to admission. All residents had risk assessment completed for manual handling, falls and some activities relating to the individual resident that were adequate. During the random inspection however one resident was found to have no risk assessment for the restriction of using cot sides, these were also not padded. It was also found that a new resident had no risk assessments A second resident had a basic care plan but it failed to describe their dementia needs and how these were to be met. The environment has yet to be adapted to promote the use of residents remaining skills. A development plan for the home to be altered was shown to the inspector during their visit. The Registered Manager must provide a development plan on how care needs are to be supported during the work to minimise disruption for existing residents. Residents spoken to during the inspection all stated that their needs for privacy and dignity were maintained. In observation staff demonstrated that they had good communication with residents and that every effort was made to protect dignity and maintain privacy, for example knocking on doors and closing them when personal care was provided. Medication storage and administration is maintained adequately. One resident required medication to be administered covertly. There was no written agreement signed by the general practioner and advocate to confirm this practice. Medical profiles did not contain the reasons for prescribed medication and what side affects may occur. This is leaving residents vulnerable if problems arose from their medication. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 11 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. The quality of meals varied and not all resident’s had their nutritional needs met. The home provides a warm welcome to visitors and keeps families updated. EVIDENCE: Residents all stated that contact with family and friends are supported and visitors are always made welcome in the home. Some resident spoken to stated that daily activities were provided and they could choose to take part. The activities for residents with a dementia were limited. The care records had small amount of information about resident’s social history but more detail would promote a person centred approach. An activity organiser works with residents in an afternoon and arranges bingo, card games, board games and music and movement sessions. Residents also enjoy visiting entertainers. Carers have only received half a day of training in dementia care and this only covered basic needs. See staffing for training requirements. The meal that was served at lunchtime was attractively presented with a choice of main meal and a dessert. The staff are concerned that residents with diabetes are not catered for especially desserts. There was often no choice because staff at head office frequently changed the food orders. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 12 The Registered Manager did not manage the budget for food and this leads to the menu being changed, as provisions were not always available. Drinks were available throughout the day. At bedtime residents have limited choice of hot drinks. Malted drinks were not always available as food orders were changed. Some residents spoken to in the dining rooms said the food was good but others were not happy with the choices available. They often decided to miss the main meal because the vegetables were not to their liking and the meat was tough. Care staff helped residents who needed assistance, but several had to wait, as there were insufficient carers to assist. One member of staff was observed to assist two residents whilst standing, it was evident they had no rapport with the residents which did not make for a pleasurable experience. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 13 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, 17,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure ensures that residents will be listened to. Not all residents have their legal rights protected. EVIDENCE: The home has a complaints procedure and records are kept of complaints received with outcomes. Residents in the main were aware of the complaints procedure and to whom to contact, except for one resident with mental health care needs. It was evident that no advocate had been sourced to ensure that their legal rights were protected. The resident complained that they were being ‘kept at the home against their wishes’ but the Registered Manager was not clear whether a Mental Health Section was in place. Staff records demonstrate that they have received training on abuse awareness and were able to inform the inspector as to what action they would take if they had concerns. A new fence has enclosed the garden and this gave added security to the premises. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 14 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): 19,20,21,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment has improved to make it more comfortable and clean. EVIDENCE: At the last inspection several requirements were made to improve the environment within the home to meet a range of residents needs. At the random inspection the following work had been completed. a) Unsuitable locks had been changed on bedroom doors b) Two bathrooms had been decorated and a third was to be completed as part of the redevelopment of the home. c) Lighting in the home was adequate and there is a stock of replacement bulbs. d) The ongoing refurbishment of resident’s room will continue and be incorporated into the new plans. e) A new fence has enclosed the garden that ensures safe outdoor space. f) The tumble drier extraction fan has been modified to prevent discharge into a resident’s bedroom. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 15 g) New storage bins have been provided for household & clinical waste. h) The corridor area adjacent to the laundry has been portioned making clear access in the corridor. i) A new front door has been fitted making it secure for residents. There are ongoing issues with the boiler that will be rectified within the development at the home. There are adequate supplies of hot water. A plumber has checked radiators to ensure maximum warmth. The building was warm and comfortable on the day of inspection. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and training do not fully meet the needs of residents. Recruitment practices ensure that residents are protected. EVIDENCE: On the day of inspection there were five carers on duty in the morning and this reduced to four in the afternoon. It was observed that at mealtime the staff team could not meet all of the residents needs that required support with their food. One carer was trying to assist two residents situated on two different tables. This led the carer to stand with very little rapport between them. The cook is available on site until after lunch. Carers in the afternoon are required to complete the teatime meal. This takes up the time of one carer. This practice reduces the care teams ability to meet resident’s needs and places them at risk. At the random visit the inspector found that there was still outstanding training requirements on first aid, but this has now been met. All statutory training was up to date. Training in relation to the care of resident’s with a dementia and mental health needs was limited to half a day on dementia care. This is not adequate training to ensure that resident’s needs are fully met by trained and competent staff. It is recommended that additional training is made available to ensure that carers are competent to meet the needs of residents as set out in the homes statement of purpose. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 17 Staff files were checked and found to contain satisfactory information and confirmed that checks had been made to protect residents. The staff rota indicates that the permanent staff team cover all absences, this leads to several staff working up to 60 hours a week. This practice makes for unsafe working and places residents at risk. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 18 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): 31,32,33,35,36,37,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The best interests of residents are not always fully met as the registered manager has limited delegated responsibility over management functions. The lack of health & safety checks does not protect residents. EVIDENCE: The Registered Manager attempts to meet the needs of residents within her limited delegated management responsibilities. It was established that due to insufficient staffing cover at the home the Manager is required to cover several shifts a week on rota. This reduces the amount of management time available and reduces her effectiveness. The manager also takes the majority of the on call backup for the home and this restricts her home life. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 19 Poorly kept Health & Safety records places residents at risk. The fire system testing on a weekly basis was not recorded and no evidence could be found that a competent engineer had checked the system and issued a fire certificate. An immediate requirement has been made after the visit to the home, as records could not be produced within the timescales agreed at the feedback meeting during the inspection. The manager and the area manager could not produce a quality assurance report so there was no evidence that resident’s, families and staff views had been sort about the quality of the service. A requirement is made for the provider to supply a copy of this report to CSCI. Resident’s monies are well maintained with the administrator at the home ensuring that correct records are maintained. Resident’s monies were checked and found to be accurate. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 20 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 2 3 2 X 3 2 2 3 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 2 X 3 2 1 1 The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 (1) Requirement All residents must have their needs fully assessed prior to admission. The assessment needs to demonstrate whether the staff have the skills in meeting identified needs. All residents must have plans of care formulated to guide staff on meeting their needs. These care plans must be individual and specific to the resident, be regularly reviewed and have evidence of the resident or their advocate having input into them. (Previous timescale of 14/06/06 & 01/11/06 not met) Specialist dietary needs of residents must be fully catered for within the menu and offer choice. Sufficient staffing need to be working at the care home to ensure that residents needs can be fully met. Care staff must receive training in Mental Health & dementia care to be competent in meeting the needs of residents cared for at the home. DS0000012910.V336044.R01.S.doc Timescale for action 01/07/07 2. OP7 15(1) 01/07/07 3. OP15 16(2) 01/07/07 4. OP27 18 (1) 01/07/07 5. OP30 18 (1) 01/09/07 The Shrubbery Version 5.2 Page 22 6 OP30 18(1) 7. OP33 24(1) (2) (3) 8. OP37 23 (4) 17 (2) 9. OP38 12 13 17 All staff working at the home must complete basic training as set by the National Training Organisation A quality assurance system must be in place at the home to ensure that resident’s views are listened to and form part of the development of the service. The latest report must be made available to the CSCI inspector. Immediate action must be taken to have the fire system tested at the home to meet Fire and Safety Order 2005 Article 17.1 An immediate requirement was made after this inspection Health & Safety practice, checks and records must comply with current legislation. Failure to do so places residents and staff at risk. 01/08/07 01/07/07 23/05/07 01/07/07 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 OP7 OP7 Good Practice Recommendations Evidence of resident or their advocate being involved in planning and reviewing care, needs to be evident and would demonstrate good practice. Residents with a diagnosis of dementia should have care plans in place to address their mental health needs. These plans should focus on their strengths as well as weaknesses. Environmental adaptations should be available to meet the needs of those residents with a diagnosis of dementia. Healthcare needs should be clearly recorded within care plans and clearly demonstrate how these are met. It is recommended that residents with a diagnosis of dementia should be cared for in a dedicated area of the home in order that both their specialist needs and the DS0000012910.V336044.R01.S.doc Version 5.2 Page 23 3. 4. 5. OP8 OP8 OP8 The Shrubbery 6. 7. 8. 9. 10 11. 12. OP9 OP9 OP12 OP17 OP25 OP31 OP38 needs of other resident groups may be met. Covert medication needs to be approved by a multidisciplinary healthcare team. Medication profiles need to give the reason for prescribed medication and instruct staff on dealing with problems arising from side effects. Activities need to be based on individual personal preferences, social histories and be person centred. Residents who do not have the mental capacity to make informed decisions need to be protected by an independent advocate working on their behalf. The problem of excessive heat in the conservatory should be addressed. Management structures within the organisation need to delegate sufficient responsibilities to enable the Registered Manager to fulfil their role. Evidence should be available that staff receive formal supervision at least six times a year. The Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 © 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 Shrubbery DS0000012910.V336044.R01.S.doc Version 5.2 Page 25 - 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!