Inspection on 25/07/07 for Uphill Grange

This inspection was carried out on 25th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Uphill Grange 18/06/08

Uphill Grange 09/01/08

Uphill Grange 29/08/06

Uphill Grange 28/11/05

Uphill Grange 23/05/05

Uphill Grange 16/09/04

Uphill Grange 20/07/04

Uphill Grange 27/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Uphill Grange Uphill Road South Weston Super Mare North Somerset BS23 4TX Lead Inspector Kathy Marshalsea Unannounced Inspection 09:00 25 & 26th July 2007 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 Uphill Grange DS0000020290.V337469.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. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Uphill Grange Address Uphill Road South Weston Super Mare North Somerset BS23 4TX 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) 01934 635422 01934 419384 uphill.grange@fshc.co.uk Acegold Limited (a wholly owned subsidiary of Four Seasons Health Care Ltd) Ms Emma Stevenson-on maternity leave Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. May accommodate up to 26 persons aged 50 years and over requiring nursing care May accommodate up to 18 persons aged 65 years and over requiring personal care Manager must be a RN on parts 1 or 12 of the NMC register. Staffing Notice dated 03/12/2001 applies Ms Stevenson successfully completes Level 4 NVQ in Care and Management by 30th September, 2006. May 2007 Date of last inspection Brief Description of the Service: Uphill Grange is registered to provide personal care for up to 18 residents and nursing care for 26 residents. The home is a converted older property in the small village of Uphill, on the outskirts of Weston Super Mare. Accommodation is provided in single and two double rooms. The majority of these have en suite facilities,but have had the hot water taps removed from each bath. A large dining room, with a small lounge area, is situated on the lower ground floor. The two main lounges are on the ground floor, and overlook the large garden and surrounding countryside. Two small passenger lifts ensure level access throughout the home. Acegold limited, a wholly owned subsidiary of Four Seasons Health Care, owns Uphill Grange. Miss Emma Stevenson was appointed home manager in November 2004 and has since become the home’s Registered Manager after the CSCI Fit person process was successfully completed. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced and took two days to complete. Two inspectors were there for the first day and one for the second. Before the visit survey forms had been sent to the home for people living there and their relatives to complete. Information from these was used to help us form judgments about the quality of the service provided. At the time of the visit there was a peripatetic (temporary) manager at the home. They were only present for the first day of the visit. Evidence was gathered in the following ways; direct observation, indirect observation, talking with staff, talking with people living in the home and reading records. During the course of the second day concerns about the care given to the people living in the home increased. Four immediate requirement notices had already been served about various health and safety issues plus some neglectful practices. The home was left in the charge of a registered nurse who was not competent. This information was passed on to the Regional Director. By coincidence one of the companys training managers visited the home, they then took control of the situation. A letter has been sent to the Regional Director with the following concerns; that the home has not been managed with sufficient care, competence and skill. A management review was held on the 26th of July 2007 to discuss our concerns about the service. A response is needed from the company in regards the management arrangements and to make sure that the registered nurses who lead shifts are competent to do so. It is also necessary for them to tell us what actions they are taking to ensure the service users receive the care and treatment they need. What the service does well: Positive comments on the survey forms included the following: “ I have found some of the care assistants to be friendly and helpful. I have a nice large like room and ensuite bathroom. I wish to make it known that this home is very lovely. The staff do their best at times and are very helpful at times. We were exceptionally pleased with our first visit. I find the staff very friendly, helpful and smile a lot. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 6 Some staff are committed to providing the best possible care they can for the people who live in the home. The home had distributed survey forms on Commission for Social Care Inspection’s behalf for people living in the home and their relatives to complete. Age Concern had been asked to come and help some of the more frail people complete them, or those who may not have anyone to help them. What has improved since the last inspection? What they could do better: There were some comments on survey forms and confirmed by our direct observations about some staff behaving in a way which detracts from peoples dignity, and creates a feeling of ill being in some people. There were immediate health and safety concerns and other concerns during our visit, these included the cleaning trolley being left unattended, the medication trolley being left unattended, people’s health care needs not being attended to and some people not being offered choices. These were all dealt with by us issuing Immediate Requirement notices. The registered nurses must respond to reports of any changes to peoples condition by the care staff. This should include checking people after they have a fall, and ensuring that pain relief is given and is effective. The care plan needs to be written in consultation with the person themselves or their representative. The plan should cover all of the persons health, social and personal care needs. Any mental health or psychological needs should also be included. The monthly reviews of the plans should record any changes and anything significant. The registered nurses must make sure that the general practitioner is notified of regular refusals of peoples medication. It is essential that all service users are treated with respect and their dignity upheld by all staff at all times. The registered nurses must make sure that all health care assessments are accurate, and that actions needed to be taken to meet that need are recorded. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 7 All staff must make sure that the people in their care choose what they do and this should include their preferred time to go to bed and to get up. The activities organiser must make sure that all service users are consulted about their social interests and the programme of activities arranged around those interests. One-to-one time of the key worker must be incorporated into the life of the home. Staff must make sure that records are kept of food intake in sufficient detail so that it can be used to determine whether their diet is satisfactory. Records should also be kept of fluid intake for those people who are more frail and need help to drink. The person in charge must make sure that any complaints received are fully investigated and that the timescales are adhered to. The person who has made the complaint must be informed about any action needed to be taken (if any). The company must make sure that all staff receive training in the protection of vulnerable adults as soon as possible. This should help staff to recognise when they are treating people neglectfully and sometimes in a degrading way. The company must make sure that the ambu chair is repaired/or placed in a first-floor bathroom. A decision is to be made in consultation about what is to happen to their ensuite bathrooms. If they are to be kept as baths safety valves must be fitted so that the hot water taps can be replaced. Urgent attention must be given to the staffs training needs as a group and individually. Records show that many of the staff group have not had training in the conditions of the elderly. This is especially true of the condition of dementia and is mentioned in the report. Alongside this training programme should be a supervision program so that staff are supported in their role. Some negative comments made on survey forms were: “Staff entering peoples rooms without knocking or knocking and entering without waiting for response”. One person had felt bullied by one nurse, which had been ignored by the manager Emma Stevenson, this person reported their concerns to the head office and felt that this was then dealt was appropriately. Another said that at times when they asked questions about their relatives’ care they did not receive answers. Another stated that when a GP or other medical person had seen their relative they were not informed. They had frequently queried this but communication from the home to the next of kin is poor. Dental treatment/care has also been poor. Theyd also stated that there are often poor cleaning standards in their room and bathroom, they are often not clean, and the bed was sometimes left Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 8 unmade when visitors arrived in the afternoon. They also said sometimes was the smell of urine on entering the home and in the corridors 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. Uphill Grange DS0000020290.V337469.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 Uphill Grange DS0000020290.V337469.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): 3,4 Quality in this outcome area is. This judgement has been made using available evidence including a visit to this service. Information about the service is not accurate or up to date so people wishing to move into the home may be misinformed. There is an assessment of a person needs before a decision is made about them moving into the home. This information is not always used to ensure that the accommodation provided meets the persons needs. Care practices for people living in the home with dementia are not based upon current good practice. EVIDENCE: Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 11 1.The temporary manager told us that she intended to update the Statement of Purpose so that the information about the change of manager was accurate. I looked at the Service user guide, which also needs to be updated. For example in the complaints procedure it talks about the National Care Standards Commission (NCSC) who may be contacted, this is two years out of date as the NCSC became the Commission for Social Care Inspection in April 2005. These documents need to be an accurate reflection of the service provided. People moving into the home need to know that they cannot have a hot bath in their ensuite bathroom, and that only one bathroom is available for all of the people living in the home, and while daily choices of food are available it is restricted to two choices. This document will be checked for accuracy at future visits. 3.I spoke with two people who had moved to the home fairly recently. In both instances their families had chosen the home for them. While they were both impressed with the building itself, they were not as impressed with the services offered. These included not being able to use their ensuite bathroom, adaptations not being in the toilet, and disappointment with the quality of the food. We were told the people are fully assessed before moving into the home. Preadmission assessments were seen in care files. As mentioned later in the report the home must make sure that they can fully meet the persons needs, and if necessary provide equipment for them before the admission takes place. This should include making sure the room is appropriate for them. 4. We were told that only four people living in the home have dementia, while this might be true for a formal diagnosis many people I met had a high level of confusion/cognitive impairment. In order to meet their needs care should be based upon current good practice and reflect relevant specialist guidance. This cannot be achieved while staff do not have the skills and comprehension of the problems associated with this diagnosis. I talked to two staff about the workbook they were currently doing for the care of dementia, they stated that this book makes them “think about being in that persons shoes” despite this both these people were seen to be doing just the opposite to that. More information about this will be detailed later in the report. This home is not registered to accept people with a diagnosis of dementia. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. The care plans are generated from an assessment but are done too quickly to give an accurate picture of the persons needs. They are not individualised and do not contain any personal or social care needs, and focus on peoples disabilities. Not enough attention is given to making sure peoples’ health care needs are fully met. This is particularly so for how falls are managed, medication is given, and that peoples food and fluid intake is enough. Some of the staff do not show respect to the people they are caring for promoting a feeling of ill being, particularly for those people who have dementia. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 13 EVIDENCE: 7. I looked at closely at the care records for four people living in the home. Two had moved to the home quite recently and two had been living at home for some time. One person recently admitted to the home had been assessed before they came in. This assessment was quite detailed. I was told by one of the registered nurses that much of the information in here was used before the person came to the home to form part of their care plan. They also said that the care plan is then completed on the day of admission. I read the care plan and various medical assessments that this person had, and then went to meet them. This person was quite able to talk to me about their experience of living in the home. It was evident that this person had been experiencing difficulties during their short time at the home, which I had not read about in their care plan. This included the fact that they had been prescribed some tablets, which were causing some embarrassing side effects. This person was also having difficulty using their ensuite toilet due to the fact that there are no grab rails in there. The fact that this person could not use their ensuite toilet was distressing to them, I would like to be able to do this on my own. They were also displeased that they were unable to use their own bath due to the fact that the hot water tap had been removed. There was conflicting information in the care plan and various assessments about some aspects of this person’s current condition. Some of this could be because the care plan was done straight away without the time to fully assess this persons needs. They also said that there had been some conflict with one of the nurses about their medication. This had been resolved by the person refusing to take one tablet which was causing them distressing side effects. There were no social, psychological or personal details in this care plan. The second plan was for someone whod been at the home for some time and had a diagnosis of dementia. This plan had been poorly written and was full of subjective and negative comments such as she wanders anywhere. There was also poor use of the English language for example under the problem of falls is recorded make accident if any. It was completely unclear what this meant. The plan showed little understanding of dementia and the effects that it can have on a person. For example under the plan about the fact this person was becoming incontinent, there were no non-verbal signs for staff to pick up on which may indicate when this person might want to go to the toilet, which could help to preserve their dignity. Staff spoken with gave varying accounts of indications this person may give of their need to use the toilet. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 14 Most of the care plan had been written in 2006 and had very little information in the monthly reviews that had been done. It was also recorded that this person can be aggressive while staff are trying to help them. This had been written in February of this year and again there was no information about whether the strategy of leaving this person and returning to them later had been successful. The third plan was for someone who had been a fairly recent admission to the home. A pre-admission assessment had been completed and from that the care plan had been developed the day after their admission. This plan had adequate detail in there and had been reviewed monthly. Despite the fact that then this person had a diagnosis of a heart condition, and had numerous entries in their daily notes about having chest pain and other symptoms this was not mentioned in the care plan. This person had also had some investigation done recently for a medical problem, a diagnosis had been made, and hospital treatment arranged, which was not recorded in the care plan. The plan for this persons ability to walk was also inaccurate, as this has improved after admission, making the manual handling assessment incorrect. None of this persons current abilities were recorded, and nor again were there any social, psychological or personal details recorded. This final plan was for a person who had been living at home for some time. This plan had been written at various times and covered some more recent problems/needs. More detail would have been useful, for example in the sleeping plan there was no preferred routine or whether this person needed medication to help them sleep. There was also some misleading information such as ring the bell every time which staff told me was not realistic. Information could have been used from the recent continence assessment for the plan of incontinence. There had also been a recent problem of this person being resistive to care interventions, again no individualised techniques or distractions were recorded. Though the risk assessment of the possibility of developing a pressure sore had also recently increased, inaccurate information about measures needed to meet this risk were present. Staff were told to continue using a divan mattress, where in fact a more suitable mattress was being used. There was no plan for dementia and the way that this condition has affected this person. Again no social or personal information was present. 8. It was evident that staff often have referred new health problems to the general practitioner. It was of great concern on the second day of the visit that two health problems had not been referred to the GP, and the registered nurse on duty was neglectful towards these two people. The first was a person who was unable to express clearly what the problem was, but care staff said they had been reporting that this lady was in pain for seven days. I spoke to the nurse about this who gave me conflicting information about whether they had known about this for some time. There had been no investigation of Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 15 whether this pain could have been due to a fall or accident. The care staff had found bruising while bathing her under her arm and on her chest. I asked the nurse to immediately call for a GP visit, and to give this person some analgesia. Once the GP had visited it became clear that he had already seen this person, but this was not recorded anywhere. Nor was the fact that this person was clearly indicating pain in their shoulder. The second incident was regarding a person who had had a fall at approximately 08.30 on the morning of the second visit. This had been reported to the registered nurse. I discovered later in the morning that this person did not seem as well as the day before, and at lunchtime staff called for help due to some bleeding from their hand injury. It was of great concern that this persons hand had swollen and that their rings were being embedded into their skin. I called the nurse who did not seem to comprehend the seriousness of the swollen fingers and the possible risks. Once again a GP visit was requested and when this was delayed it was possible that a call to the emergency services may have been necessary. Following these two concerning incidents action was taken to remove this registered nurse from the position of being in charge. The companys representative arranged for a registered nurse from another home within the group to come and take over the shift. These matters need to be investigated and then the appropriate action must be taken for this registered nurse. They also took charge of making sure that these two people received the appropriate treatment and care from the staff. As previously mentioned risk assessments are done to identify those people who are at risk of developing pressure sores, so that appropriate action to reduce that risk is recorded in their plan of care. I looked at three of these wound care plans, they were adequate details in the plans but not always in the initial wound assessment forms, which should give a baseline for other staff afterwards to gauge any improvement or deterioration. Continence assessments were present in the files I read. None of the information in there was transferred to the plan of care for this problem, and in some instances the information was inaccurate. I checked the accident records from May 2007. I checked the files of two people who had had more than one fall. It was clear that staff were not reevaluating the risk to each person after an incident. No additional safety measures seemed to be taken for anybody in the home at high risk of falling, to lessen the risk of them falling. In some instances additional risks such as placing a bed table in front of them were used. In the case of the person falling on the morning of the visit, the companys representative asked staff to remove the bed table and then check that this person was safe every five minutes. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 16 I asked care staff about any records they kept of safety checks; the only ones used were for checking people who have bed rails every 15 minutes. These checks were seen. It was noticed in the records and from my observations that there was a significant amount of skin flap injuries. These could be due to carelessness by staff when moving people transferring them. These high number of incidents need to be investigated. Nutritional assessments are completed for each person. It was seen that people are weighed regularly. For those people at risk of being malnourished and dehydrated extra measures to help them were not in place.(see Standard 15). The companys representative agree that at least two people appeared to show signs of dehydration and asked staff to be extra vigilant in helping these people to drink. The chiropodist was visiting the home on the first day of the visit. As some people are already in the communal lounge these people were treated in there. No screen was used to preserve their dignity while they were having this treatment. 9. Medication records were not looked at in detail but while looking at the record of medicines administered I saw that there were a lot of refusals recorded. This was discussed on the first day of the visit with the registered nurse. It was unclear whether regular refusals were being reported back to the GP. We discussed the case of one person who has a diagnosis of dementia. The continual refusal of some of their medication may have been adversely affecting their general condition and the way they behave. The practice of concealing necessary medication in food was discussed with reference to the recent Mental Capacity Act. It was agreed that in this case, for this particular decision, it would be in a persons best interests to conceal their medication. The nurse agreed to contact the GP and relative to inform them of the decision and get their agreement. This will need to be carefully recorded. One survey form stated that changes were made to medication without the persons knowledge or consent. Medication records will be looked at more detail at the imminent follow-up visit. 10. Throughout the report there is reference to some staff not treating people with respect and upholding their dignity. Our observations during our visit included staff talking about a person to each other while they were with that person without including them, talking in communal areas about peoples behaviour/condition, not describing what meal they were helping them with, moving them without telling them what they were going to be doing, and choices not being given. An example of this was on the first day of the visit. As staff brought people from the dining room to the lounge some people were given the chance to sit in comfortable armchairs, and some people were left to Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 17 sit in their wheelchair. The Registered nurse was heard asking staff to make people comfortable in the lounge. A while later four people were still in wheelchairs parked haphazardly in the lounge. Staff were seen doing tasks such as distributing clean laundry. I asked a carer about the four people who were still in their wheelchairs. She replied that they would either be going to their rooms later or back to the dining room for tea. This was not acceptable so I asked that they were given the choice of sitting in an armchair. Three people accepted this choice. This took at least another 25 minutes to action. Staff did not appear to be working as one team, as in order for this to happen staff from upstairs had to be asked by the registered nurse to come and help their colleagues. The comfort of the people living in the home should be the first priority of all of the staff, and must come before tasks. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 18 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): 12,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are various activities organised, but there is little provision for those who do not wish to or cannot join in. There is not enough attention given to people having enough to eat or drink. The teatime meal is repetitive and unpopular. Those people unable to make a verbal choice about their meal are not given choices. EVIDENCE: 12.The acting manager said that the home had just taken on a new activities co-ordinator who would be spending 20hrs a week with people and putting on a range of activities. The newly appointed person had been in post one week, and had already written a newsletter for August that gave information about her background, services such as the trolley shop, a proposed summer fete and August activities. These are to take place Mondays to Fridays. The range of activities planned included videos and DVD’s, outside entertainers, vase Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 19 painting and pastel drawing and exercise games. The newsletter was seen pinned up on the ground floor of the home and in people’s rooms. However it wasn’t clear how much input people living at the home had had in choosing activities, and some such as finger painting could be patronising to older people. It wasn’t clear if any of the activities had been designed as suitable for those people with dementia. The co-ordinator hadn’t yet been offered training in planning activities with particular regard to suitable activities for people with dementia. This should be done as soon as possible. 15. I observed the lunchtime meal on the first day. This is served at about quarter to one and as mentioned previously the dining room is in the basement of the building, and only accessible by one of the passenger lifts. There was poor organisation of this meal, this could possibly be because staff had been speaking to one of us, so were delayed in their usual routine. Because the room is so spacious there are plenty of tables for people to choose where they sit. Some people were sat on their own, and some people were sat in groups. The meal is served from a servery relocated out of sight of most of the people sat at tables. I had been told that people chose what they eat for their lunch the day before. It was clear that there were some people who would not be able to make that decision. Despite this a choice had been made for them, and one person with dementia did not eat the meal that she was given, was not given an alternative meal, only sandwiches, and indeed said to me that she would have liked the alternative meal. Some of the staff brought people to the tables in their wheelchairs and were very careless about paying attention to where the peoples feet were. In one incident a person’s foot was dragging on the floor, but the care assistant did not notice this, and she repeatedly tried to push the person nearer to the table. It was seen that this person already had some sort of injury to her calf as she had blood underneath her tights. This injury was reported to the registered nurse. I did not observe the cook talking to any of the people about whether they enjoyed their meal. Some people needed help to eat their meal; one care assistant was seen doing this. They did not explain to the person what they were giving them for the three courses given. This process might also be more dignified if staff had used teaspoons instead of dessertspoons. It was seen that minimal eye contact was made between the two, and the care assistant did not attempt to make conversation, or ask the person if they were enjoying their meal. I asked several staff about what happens if someone doesnt eat their meal. There were varied responses to my question, but there was no reassurance that if the meal wasn’t eaten that this would be compensated for later in the day or recorded. I listened to the handover and heard the late shift being told that the person mentioned above who had not eaten their meal, had eaten well. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 20 I was also concerned about whether staff were offering sufficient drinks to some people living in the home. This was particularly so for the more frail and confused people. Two people in particular who were very frail seem to have some signs of dehydration; this was more evident on the second day of the visit. The survey forms we send out asked the question do you like the meals at the home. Two people said always, four people said usually, four people said sometimes. I asked people I met during the visit about whether they like the meals, some said that they were okay but were unhappy about the repetition of the teatime menu. Others were noncommittal. I was told that while there are two choices for the lunchtime meal but there is no alternative to that if someone did not like the choices, or just did not feel like eating those choices. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 21 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 poor. This judgement has been made using available evidence including a visit to this service. Complaints made are not always dealt with and not being recorded. There are abusive care practices taking place and staff have not received the training to understand this. EVIDENCE: 16.The company does have a complaints policy, which is available in the Service user guide and is displayed in the main hall of the home. Survey forms we sent out included the question do you know who to speak to if youre not happy three said they would, three said they sometimes would, one person said they never would. 10 people said that they were aware of how to make a complaint. A person did say that they had made complaints, which had been ignored. The Commission for Social Care Inspection received two complaints before the inspection visit. One was regarding concerns about there being no manager at the home, the other was from a relative regarding the care of their spouse and the subsequent poor response to their complaint from the companys representative. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 22 It was evident during the course of our visit that people had not been kept informed of the changing situation with the various managers. This also included the change of regional manager. People living in their home and their relatives should be kept fully informed of the situation by whatever means is necessary. The second complaint mentioned above is still being checked to make sure that it has a satisfactory resolution for the person who made the complaint. This will be followed up by the Commission for Social Care Inspection. I looked at the complaints log kept in the home. There were three pieces of information in the folder for this year. The first two were letters received after our random inspections; one visit was done to discuss the complaint mentioned above. The other was an e-mail from the manager to her regional manager about some difficulties they were having meeting somebody’s needs. There was no following information to see whether this situation had been resolved. The log should include details of any investigation and any action taken. During the course of our visit we were both told about various complaints that have been raised over the past few months. These included complaints about the quality of the food, missing laundry and possessions, and concerns from staff about the way they were being directed by some of the registered nurses to put people to bed against their preferences. None of these had been recorded. One person did say that since they had complained about the quality of food that this had improved. 18.Some staff observed during our visit showed poor communication with people that they were caring for. In some instances staff started doing a task such as moving the persons wheelchair, giving them a drink, giving them some food, or moving them without telling them what was going to be happening. I had been given information before the visit and during it about staff ignoring people, and talking over them while they were supposed to be caring for them. This was seen quite often over the course of the two-day visit. One person said that this makes them feel as though they are an object and not a person. With these observations and the practice of putting people to bed in the afternoons against their wishes and preferences, our judgment was that there had been and was some institutional and abusive care practices. Staff spoken with were asked about their awareness of abuse. They showed poor levels of knowledge and some were unaware that a recent visit to the home by inspectors and police officers to raise awareness had taken place. Staff were hazy about what types of abuse there are and what their responsibilities were in reporting it. No individual training records were available to show when if any training in the issue was done. Registered nurse files looked at showed that no Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 23 safeguarding adults training had been done or picked up as a training issue. The manager showed us a training ‘matrix’ – a sheet that had all the dates of any training attended by all care and nursing staff. She said that a proper training plan was usually in place in other homes in the Four Seasons group she had worked in, but couldn’t be found at Uphill Grange, so she had done her own. The matrix showed that only one of the six registered nurses had done abuse training. The only training done for one had been in May 2005. Further, only ten out of 18 care staff had done it and the last date attended was September 2005. Abuse is covered in the induction standards but no completed records were seen of this. Staff said that they hadn’t been given copies of the Department of Health guidance ‘No Secrets’ and were largely unaware of its importance or value. I saw a copy of this near the nurses’ desk. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 24 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): 19,20,21,22,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not fully adapted to meet the physical needs of the people living in the home. The choice of having a bath in any en suite facilities has been removed, and there are inadequate bathing facilities for the amount of people living in the home. The hot water system does not give a consistent supply of hot water and reliable heating. EVIDENCE: Uphill Grange is an 18th-century house with distinctive architecture and décor, which has had some adaptations and refurbishments in the past so that it could be used as a care home. Both inspectors toured the home and looked at Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 25 individual rooms together with lounges and the dining room. It’s laid out over three floors with the dining room on the lower ground floor, lounges and bedrooms on the ground floor and bedrooms on the upper floor. There is also a top floor with at least four rooms, but people living at the home don’t use these. There are spacious grounds which are accessible by ramps. There are two very small passenger lifts, which go to each floor. This is used for taking people down to the basement floor, where there is a large dining room. This floor also contains the kitchen staff room and laundry area. There seems to have been little investment in the renewal of the fabric and decoration of the building recently. This is not in keeping with the external building which is extremely impressive. There are two communal lounges on the first floor, one of which was used mostly during the visit; the other is now mainly being used for when group activities take place. We had concerns about the washing and bathing facilities for the people living in the home. There is a large bathroom on the first floor, this has not been able to be used for at least a period of six months, due to the fact that the assisted chair that is fitted to the bath had broken, and has not been replaced. The only other bath in the building is on the top floor which is not being used as a residential area. Staff had expressed their concern about this to the registered nurses and been told to use the hoist. The bathroom was seen. Whilst it was big enough for an ambulift and for two people to assist, it was not laid out properly for a hoist to be used safely or comfortably for both people living at the home and staff. The side panels of the bath had been removed to enable the hoist to fit. Staff said that they remained concerned about the welfare of, in particular, people with dementia as they become distressed when hoisted in and out of the bath. This is very unsatisfactory. There is not the opportunity for anyone to have a bath in their ensuite bathroom. This is because of the risk of scalding from excessively hot water temperatures, which is not been properly addressed. Restricted valves which could have been fitted to the hot water outlets to these bathrooms (so that the water temperature could be controlled) have not been fitted. This has been the situation through a period of at least three years and is unacceptable. I spoke with one new resident who said that they had been looking forward to having a bath in the convenience of their own room, had not been told that this was not possible, and was very disappointed. The acting manager said that plans were in place to put the valves in and replace bath taps but there was no clear timescale for this. However, the handyperson said that work to replace the valves for washbasins only was due to start on 30 July 2007. The National Minimum Standards for Older People recommend that there is a ratio of one assisted bath to eight people living in the home. This ratio needs to be met as soon as possible, and people who live in the home consulted Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 26 before decisions are made about changing bathrooms to wet rooms, which is being proposed by someone in the company. The communal toilets seen during the visit did have grab rails to help people, however this was not the case in all of the bedrooms seen. One person I met was struggling to retain their independence in using the toilet in their room, which was being hindered by the fact that there were no adaptations to help them. (See Standard three). There are no facilities, including communication aids such as the loop system, for those with hearing impairments, visual impairments, and there are no signs to assist people who have dementia or other cognitive impairments. Protective radiator covers were seen in all areas of the home which are used by the people living there. This had been a requirement made at the last two inspection visits. Two people spoken with, and one person on the survey form, raised concerns about the inadequate heating and inadequate hot water. Some of the larger bedrooms did feel cold and many of the bedroom doors were left open while the rooms were unoccupied. I spoke with the maintenance man about the problems with the hot water temperatures. He said that there was an old system, which meant that there were variable water temperatures throughout the day. This needs to be checked and actions taken to improve the system, and ensure that the home is kept warm. There were positive comments in the survey forms about the standard of cleanliness in the Home. Seven people said that the home was always fresh and clean and two said usually. The home employs a housekeeper and a team of domestic staff. On the first day of visit a cleaning trolley with various chemical cleaners was left unattended in a main corridor where people living in the home were. This happened for a period of at least 30 minutes. The person spoken with realised that this should not have happened and said that they didnt usually do that. The laundry facilities were not checked at this visit. Two survey forms stated that they found the beds to be very hard. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 27 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 poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate to meet the needs of people living at the home, but the skills of some of the trained nurses are not adequate to direct care, putting people at risk from harm. The home has failed to make sure sufficient numbers of staff have achieved the national vocational qualification in care, or other training to give staff the skills to meet the needs of the people they are looking after, Satisfactory checking of staff before employment makes sure people using the service are protected. EVIDENCE: 27.Fifteen care staff currently work at the home to care for 25 people living there. The manager said she was interviewing for two full time care staff vacancies and a deputy manager on the first day of this visit. No agency staff are used but the home uses a lot of bank staff. A number of care staff were spoken with at this visit. They said that They felt there was enough staff on each shift. One person had Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 28 recently started and was doing 12 hours care and 20 hours as Activities co-ordinator. Staff said that two staff meetings had been held since the new acting manager had taken up her post ten days previously. The first meeting had been a general one. Staff hadn’t however been given copies of any minutes from this meeting. The second one had been held on the day before this visit to deal with a situation that negatively affected people living at the home. A relative had complained that residents were being put to bed early each afternoon and they stayed there. This denies them choice and leads to boredom and inactivity. Staff admitted this had been happening and despite their raising concerns about it nothing had been done. However staff also said that people were able to choose when to get up in the morning and were not pressured into doing so too early. Staff said they were impressed with the manager’s handling of the situation and felt confident that things would improve. However it wasn’t clear whose responsibility it was to make sure the rest of the staff team that didn’t attend the meeting were given feedback about the decision made. No notes were seen that confirmed the actions to be taken. Staff said that morale had been low for some time. They said that they felt this was because there had been at least four temporary managers since the permanent manager had stopped working. Each of the temporary managers had different ways of working and staff had been told to do different things that had led to confusion and frustration. However they were feeling more confident since the current temporary manager had started work. Staff also said that they had welcomed talking with us, as they haven’t been given opportunities to discuss issues or felt that they’ve been listened to for a long time. Staff said that they felt there were enough staff on each shift but they don’t get opportunities to give much key time – one to one time that is of more social benefit to people living at the home. A key worker system is used and each staff member cares for three individuals. Although this works well often there isn’t enough time to do things like shopping. This has to be passed to other staff to pick up and sometimes doesn’t happen. 28.Of the fifteen care staff the manager said that two staff are trained to National Vocational Qualification in Care Level 2 and that a further five were doing it. One senior carer has a nursing qualification that is equivalent to National Vocational Qualification in Care, but isn’t registered to work in this country. From this it’s clear that the home still doesn’t meet the 50 recommended minimum number of staff trained to Level 2 or equivalent. The NVQ assessor was seen in the home at this visit and one staff member confirmed that she would be meeting with her later in the day to go over her work. The manager said that she is also an assessor and would be doing some of this work. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 29 A comprehensive and detailed induction standards book was seen that is given to new staff to work through when they start. The book contained sections on principles of care, safeguarding adults, person-centred approaches and safe systems of working among others. An induction sheet for the first day was also seen that a new staff member fills in to show that they have familiarised themselves with daily living routines, meeting with people living at the home and receiving instruction in essential health and safety matters such as fire safety. 29.Three care staff files and one registered nurse’s file were closely looked at during this visit. Each file met the requirements of the Care Homes Regulations in respect of recruiting staff. Files held all recruitment and selection information including: Application forms Two written references Statement of health and fitness to work Interview notes, and Proof of identity and photographs of each staff member. Evidence of the home seeking information from the Criminal Records Bureau so that a person could start work before the formal clearance document was sent, was seen in one person’s file. In others evidence of the disclosure documents was seen but not the full certificate. This made it difficult to see when the documents had been received as there was no date on them. Details of interviews and disciplinary matters were seen. Some of these weren’t detailed enough and it was hard to see how decisions had been made. Staff files also included training certificates –although all those seen were from previous employment or were very outdated. No recent training certificates were seen for any staff. Staff said that they hadn’t had any recent training in caring for people with dementia, although they had been issued with a ‘workbook’ that they didn’t find easy to work with. A trainer had attended a couple of sessions to go through the workbooks with them, but hadn’t been seen for some time. Staff knowledge of dementia awareness and care was poor and from observation their attitudes weren’t person-centred. From this it was clear that registered nurses that have responsibility for managing care on a day to day basis, including developing care plans, supervising and supporting staff, had done little but the most basic training e.g. in moving and handling, health and safety and fire safety. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 30 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): 31,32,36,37,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who live and work in the home have not had consistent management since May 2007;this has had a detrimental effect on how the home is run. The home is not being run in the best interests of the people living there. EVIDENCE: 31.The registered manager Emma Stevenson went on maternity leave in May 2007. The Commission for the Social Care Inspection had not been informed that several peripatetic managers had been to the home since, staff reported that there have been at least four of these managers. We met the current peripatetic (temporary) manager, Mrs Linda Burgess, during this visit. She Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 31 had been working at the home for 10 days at the time of our visit. She told us that she had been asked to stay there until at least October 2007, which would be the end of Mrs Stevensons maternity leave. Mrs Burgess is a registered general nurse and has been working for Four Seasons Health care homes since 1995. She has been working as a peripatetic (going to each home temporarily) manager for the company since 2003. During our discussions with her, and from information given by staff such as ‘Linda’s brilliant – she acts straight away and picks things up. She won’t have any mucking about or be walked over’, Her priorities were unclear and she could not describe to us her action plan while she was at the home apart from the fact that she had sorted out the rotas. She did not give us information about any concerns she had about poor care practices, and indeed commented positively about most of the staff, in contradiction to our experiences. She had not held a formal residents/relatives meeting yet but said that she went to the dining room every day to meet the people who were in there. As some people do not go to the dining room for their meals it was unclear if she had met them. We stressed the importance of people being informed about her being there. Another issue that she had dealt with (after receiving a complaint from a relative) at a staff meeting was the fact that some of the trained nurses had been asking the care assistants to put some residents to bed early in the afternoon, to lighten the workload later on in the evening. Mrs Burgess said that she was very clear here with staff in the meeting that this was not acceptable, and that this was to be passed on to their colleagues. We were concerned that this information was not going to be passed on quickly enough so that this practice stopped altogether. Mrs Burgess said that the minutes of this meeting would be typed out and given to all staff. Care assistants spoken with during the visit were relieved that they were going to be supported in them not wishing to do this. At the time of the visits there was no regional manager for the company who would be responsible for monitoring the home, and doing the monthly and unannounced Regulation 26 visits. Due to the deterioration in the standards of care within the home this must become a matter of priority, and reports resulting from these monthly visits must be sent to the Commission for Social Care Inspections local office. Mrs Burgess informed us that she is planning to do some moving and handling training with all of the staff very soon. It was of concern to me that there seemed to be a high number of skin flap injuries, which could be caused by careless handling or at worst inappropriate handling. At the point of our visit this had not been investigated or audited. This will also have to be done as a matter of priority. I observed several instances of staff helping people to Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 32 transfer from armchairs to wheelchair and then back again. In some instances instructions were not given to the person being helped leading to confusion which staff handled poorly. It was noted that there were hoists on each floor of the home but not on the top floor where the parker bath is. 36.Staff spoken with said that they don’t get supervision very often – ‘about once every six months’. They were unaware of the National Minimum Standards guidance i.e. supervision should be given at least six times yearly. Staff said they sign their supervision record but aren’t given a copy so don’t remember what had been discussed and actions agreed. Very few supervision records were seen in the four staffing files looked at. One person had one supervision record that had been filled in. Annual appraisals – a review of individual staff and their work - were seen in all files but only one was filled in by both staff member and supervisor. In other files the staff member that the appraisal was about had just filled in their part, so the appraisal wasn’t meaningful. From training records seen none of the registered nurses that were regularly doing supervision had done training in supervision skills. Staff also said that they felt a lack of support from the registered nurses. They said that only one of the six registered nurses was supportive of their work and worked alongside them, teaching and explaining things to them. This person’s appraisal record was seen that confirmed her/his willingness and enjoyment of teaching and supporting staff. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 33 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 2 X 1 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 X 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 3 1 1 X x 1 2 STAFFING Standard No Score 27 1 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 X X X 1 1 1 Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 34 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 OP26 Regulation 13(4)(a) Requirement Timescale for action 2. 3 OP10 OP9 12(1)(2)( 3)(4)(a) 13(2) 13(4)© 4 OP8 12(1)(a) 5 OP7 15(1)(2) ©(d) The registered person shall ensure that service users are 25/07/07 protected from hazardssubstances hazardous to health must be locked away when not in use. The registered person shall ensure that service user’s needs 25/07/07 come before tasks. The registered person shall ensure that the medication 25/07/07 trolley is not left unattended when unlocked with tablets on the top of the trolley. The registered person shall ensure that the registered 26/07/07 nurses respond immediately to reports of pain, falls and changes in any person’s condition. The registered person shall ensure that the care plans are 30/09/07 written in consultation with the service user or their representative, revise the plan where appropriate and notify the service user of those changes. The plan should cover all of a persons health, social and personal care needs. DS0000020290.V337469.R01.S.doc Version 5.2 Page 35 Uphill Grange 6 OP9 13(2) 7 OP10 12(4)(a) 8 OP8 12(1)(a) 9 OP12 12(3) 10 OP12 16(m)(n) 11 OP15 Schedule 4.13. 12 OP16 22 13 OP18 13(6) 14 OP18 13(6) The registered person shall ensure that the GP is notified of regular refusals of service users medication. The registered person shall ensure that all service users are treated with respect and their dignity upheld by all staff at all times. The registered person shall ensure that health care assessments are accurate and that actions needed to be taken to meet that need are recorded. The registered person shall ensure that service users choose what they do including their preferred time to retire to bed and get up. The registered person shall ensure that service users are consulted about their social interests and the programme of activities arranged. The registered person shall ensure that records are kept for service users in sufficient detail to enable any person reading the record to determine whether the diet is satisfactory, in relation to nutrition and fluids. The registered person shall ensure that any complaints are fully investigated and shall within 28 days after the date on which the complaint is made, inform the person who made the complaint of the action (if any) to be taken. The registered person shall ensure that service users are safeguarded from neglect and degrading treatment. The registered person shall ensure that all staff are trained in the Protection of Vulnerable Adults. DS0000020290.V337469.R01.S.doc 26/07/07 26/07/07 26/07/07 26/07/07 31/08/07 26/07/07 31/07/07 26/07/07 25/08/07 Uphill Grange Version 5.2 Page 36 15 OP21 23(2)(j) 16 OP21 23(2) 17 18 19 20 OP21 OP30 OP36 OP33 23(2)(j) 18 18(2) 26 The registered person shall ensure that there are sufficient numbers of baths fitted with a hot water supply. The registered person shall ensure that the ambu chair hoist is repaired/replaced in the first floor bathroom. The registered person shall ensure that restrictive valves are fitted to the hot water outlets. The registered person shall ensure that staff are trained and competent to do their job. The registered person shall ensure that all staff are appropriately supervised. The registered person shall ensure that Regulation 26 reports are sent to the Commission for Social Care Inspection. 31/08/07 31/08/07 31/08/07 30/09/07 30/09/07 31/08/07 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 Refer to Standard OP36 Good Practice Recommendations Staff should receive supervision at least six times a year. Uphill Grange DS0000020290.V337469.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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