Department of Health and Social Care Rheynn Slaynt as Kiarail y Theay

Inspection Report

Regulation of Care Act 2013

Adult Care Homes

Gansey unit

Unannounced

11/01/2017 9.00-16.20 18/01/2017 9.00-14.00

Registration and Inspection Unit 3rd Floor, Murray House, Mount Havelock

Douglas, Isle of Man, IM1 2SF

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Contents

Completing and returning your report

To complete your report form, enter text by clicking on the box see the instructions below. Use the tab key to move to the next box. 1. Provider’s action plan

a. Add details of your actions to complete the requirements/recommendations (if applicable)

2. Provider’s comments/response

a. Confirm you have read and agree/disagree the contents of the report by clicking on the appropriate box

b. State any factual inaccuracies found, add comments (if applicable) c. Sign (type name when returning electronically) and date

3. Return your report to randi@gov.im within 4 weeks

4. Do not use any other method e.g. links to Cloud or other file sharing services This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection.

Part 1: Service information

Part 2: Descriptors of performance against Standards

Part 3: Summary of Inspection Outcomes

Areas of good practice Quality improvements subsequent to the previous inspection

Areas for improvement Demeanour of and feedback from service users

Part 4: Inspection Outcomes and Evidence and Requirements

For this inspection the Unit has decided to inspect the following key groups of standards, taking account of the outcomes of inquiries into Winterbourne View and Mid-Staffordshire NHS Trust and given our knowledge and experience of services currently inspected on the Isle of Man: Standard 2 - Daily Living Standard 7 - Management, Quality and Improvement In addition the following areas will be considered in each inspection:

Provider’s Action Plan

Click here to enter text.

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Statement of Purpose Complaints Safeguarding Health and Safety (specifically fire safety, electrical installations, central heating and boiler maintenance) Accidents and Incidents Public Liability Insurance Staff Rotas Dependency Assessments

Part 5: Previous Requirements and Recommendations

Compliance with requirements and good practice recommendations from previous inspections Requirements and good practice recommendations identified from this Inspection.

Part 6: Provider’s comment / response

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Service Information

Name of Service Southlands Gansey Unit Tel No: (01624) Registration number ROCA/P/ Not applicable Address Southlands resource centre Church road Port St Mary Isle of Man IM9 5NL Conditions of Registration Gansey Unit is a Department of Health and Social Care establishment and therefore is not subject under current Isle of Man law to the registration process. However, this Government resource is subject to inspection as an adult care home under the Regulation of Care Act 2013, Regulation of Care (Care Services) Regulations and the Isle of Man Minimum Standards 2013. Brief Description of Service and Services Provided Gansey Unit is a residential adult care home specialising in caring for older people who live with mental illness and/or dementia. The unit can accommodate up to twelve people. Establishment/Agency Information Email Address: Name of Registered Manager Edward Humphreys (not registered) Registration number ROCA/M/ Not applicable Type of Establishment Residential adult care home - EMI Date of latest registration certificate not applicable Assessed risk level of service: Pre-inspection Low Post-inspection High Date of any additional regulatory action in the last inspection year (ie improvement measures or additional monitoring risk level increases. None Date of previous inspection 03/02/2016 Number of individuals using the service at the time of the inspection Eight (8)

Person in charge at the time of the inspection Edward Humphreys Name of Inspector(s) Egle Leadley

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Descriptors of Performance against Standards

Inspection reports will describe how a service has performed in each of the standards inspected. Compliance statements by inspectors will follow the framework as set out below. Compliant Arrangements for compliance were demonstrated during the inspection. There are appropriate systems in place for regular monitoring, review and any necessary revisions to be undertaken. In most situations this will result in an area of good practice being identified and comment being made. Recommendations based on best practice, relevant research or recognised sources may be made by the inspector. They promote current good practice and when adopted by the registered person will serve to enhance quality and service delivery. Substantially compliant Arrangements for compliance were demonstrated during the inspection yet some criteria were not yet in place. In most situations this will result in a requirement being made. Partially compliant Compliance could not be demonstrated by the date of the inspection. Appropriate systems for regular monitoring, review and revision were not yet in place. However, the service could demonstrate acknowledgement of this and a convincing plan for full compliance. In most situations this will result in requirements being made. Non-compliant Compliance could not be demonstrated by the date of the inspection. This will result in a requirement being made. Not assessed

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Summary of Inspection

This is an overview of what the inspector found at the time of the inspection. The purpose of this inspection was to:

Check the service’s levels of compliance with standards and regulations as set out in Part 2. Areas of good practice: It was evident that efforts were made to improve and adapt the environment to ensure that a therapeutic dementia care environment was provided to the residents. The work is ongoing and the manager was able to share some future plans with the inspector. Quality improvements subsequent to the previous inspection: Ten out of fourteen requirements made during the last inspection were met, one partly met and three not met. Areas for Improvement: The requirements were made in the following areas:

The manager must ensure that support plans are updated in line with needs and abilities assessment reviews;

The manager should ensure that there is one consistent approach used to record and store residents records;

There must be a written induction and clearly identified process to assist and support the new manager to develop his management skills;

The manager needs to ensure that Policies and Procedures kept in the paper file correspond to the policies available to staff in the governments shared files;

Policies and Procedures need to be reviewed and updated within the timescales identified; The manager must ensure that an annual report introduces a written

development/improvement plan based on the outcomes of the quality assurance assessment exercise, as well as list success of the service;

The manager must ensure that supervision and any performance management records are kept in line with Data Protection Act 2002;

A written policy needs to be displayed in the home informing people of their rights to access their files and records at any time. Where access in restricted this is explained to individual;

The service manager or the quality and performance improvement manager must conduct twice yearly visits to the home and assess in relation to the premises, staffing levels and skills, service user/representative satisfaction and record keeping. After which the reports must be produced and shared with the home manager for consideration when compiling the annual report for the service;

The manager must review the statement of purpose to ensure it is accurate and contains up to date information;

The manager needs to ensure that there is one clear complaint policy and procedure for everyone to follow;

The manager needs to evidence that a copy of the Isle of Man Government Inter Agency Adult Protection Policy and Procedures 2016-2018 is read, understood and complied with by all staff at the home;

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A Confidential reporting (Whistle blowing) policy must be reviewed and updated accordingly;

The manager must ensure that all staff members have Adult protection refresher training in timely manner;

The manager needs to ensure that weekly fire alarm tests; monthly firefighting equipment (including emergency lighting) checks and bi annual fire drills carried out and appropriately recorded;

All portable electrical appliance tests must be carried out and recorded in compliance with current guidance and instruction;

Electrical installation certificate must be available to see; The manager needs to ensure that pre-employment check information for all the staff is

available for the inspection; The manager must ensure that all new staff members have a written induction programme,

which is followed and signed off by supervisor and inductee; The manager must ensure that all staff members have regular 1 to 1 supervisions to meet

the requirements of the standard;

The manager must ensure that all staff members receive all mandatory training and identified refresher sessions required in timely manner;

The manager needs to ensure that all staff members have an annual appraisal of their performance;

Staffing levels and staff deployment need to be determined following a regular written dependency assessment of residents needs. The assessment needs to include reference to the layout of the home and the skills mix and experience of the staff team.

Demeanour of, and feedback from, residents Residents were in clean, appropriate clothing and looked well cared for in respect of their appearance. Staff members were observed speaking to residents in a calm respectful way. The inspector had an opportunity to speak to one relative and four members of staff. Questionnaires were also left for residents, family members/ friends to complete as well as staff and professionals involved with the home. One relative, one staff and one professional’s questionnaires were returned. Some comments made were:

in regards to food: “Alright, sometimes it is not good. There are systems of complaint/comment

to the chef”; “I have only seen photos, but they certainly look good”; “Alright”; “Good and bad. Some suppers are not up to standard or not enough.

Residents are asked”; “Lunch – good, evening need to improve in quality and quantity”; “It depends. Sometimes a bit basic”; “The menus are satisfactory and again present opportunities for

development, such as nutritional finger food.”

In regards to facilities and equipment: “Could do with a shower room”; “Couple of things could be changed. E.g. wet room”; “bathrooms could be better, equipment a bit old”; “One (bathroom) will be converted to the wet room”; “The moving and handling equipment sufficient. Equipment for “meaningful occupation” is very limited”;

In regards to activities:

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“this is an area that would most benefit from practice development, Activities are mostly group activities and personalised activity is not so widely offered”;

“Happens if residents want to get involved”; “Try our best to engage residents”; “Some residents engage. (there is) One very keen staff member who

organises different activities”;

General from relatives: “Christmas day was happy and jolly. (Relative) so much happier since her

came here”; “I am very very impressed with the staff and nothing seems to be too much

trouble”; “Seems to be less (staff) at weekends”; “(staff) friendly and nice”

Staff in regards working at the home: “(I feel) supported by the team , not senior management”; “Staff worried about future”; “ Changes in senior management unsettled the team”; “Happy team”; “Enough staff; smooth shifts. Everyone knows their jobs”; “Hope it stays the happy unit as it is”; “Manager changes – good. New manager – positive”; “ nicest from the few (homes) I worked in”; “I have noticed regular staff a bit unsettled by the changes”; (Do you feel happy at work?) “Mostly and I am learning a lot. Sometimes I

am concerned about the negative approaches to suggested practice initiatives”.

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Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9) Standard 2 - Daily Living

OUTCOME: Daily Living - People are supported to set and carry out their activities and routines in suitable surroundings. The environment is conducive to people’s well-being and safety. People live in a home that is safe, warm clean and comfortable. People have access to the aids, equipment and facilities they need.

Our decision: Substantially compliant

Reasons for our decision The inspector had a tour around the home. The home was in a good state of repair, clean and tidy. It was evident that a lot of work has been done to adapt the environment to ensure that a therapeutic dementia care environment was provided. The work was on going and the manager shared some further ideas with the inspector. The home had various wall murals and different textures, colours, patterns wall art around the home. A homely feel was created in the living room with appropriate décor and furnishings. The sensory room was equipped to provide calm and relaxing environment. The garden area was decorated with fishing paraphernalia. The dining room was bright and tidy. Chairs had arms rest and slider and were designed to promote independence. The manager explained that they were trying to created “café” feel in the dining area. A menu board pictorially displayed the choices of the meals for the day. One of the staff members explained the concept of the “protected meal times” to the inspector. All of the bedrooms within the home had en-suite WC and basin facilities. In addition to en-suite facilities, the home had two communal bathrooms and two toilets. Bedrooms seen by the inspector were personalised with residents own belongings. Bedroom doors were personalised with name plaques and pictures. Bedroom doors had locks on them that could be overridden by staff in case of the emergency. People were able to control heating, light and ventilation in their bedrooms, or supported to do so. The home had a range of aids and equipment installed and available to meet the needs of the residents; grab rails, bath hoists, raised toilet seats, hoists, sensory mats etc. All bedrooms had a call alarm system fitted. The manager explained that residents had an access to the cordless phone. The phone was kept in the office and was available at the request. Wireless internet connection was also available for the residents who had their own gadgets. The inspector had an opportunity to examine some randomly selected resident records. Resident records were kept in a paper files, on RIO recording system, as well as computer files in the shared area. The files seen contained comprehensive needs and abilities assessments, support plans, risk assessments and “this is me” documents. The documentation covered variety of care needs including morning/bedtime routines, eating preferences, bathing preferences, general likes and dislikes, medical history, social activities etc. Majority of the file evidenced of regular needs and abilities assessment reviews involving families in the process. Where residents were unable to participate, this was documented. In one case the resident needs and abilities assessment was updated, however this was not followed with an update to the support plan. The manager needs to ensure that support plans are updated in line with needs and abilities assessment. Overall the documents were comprehensive and detailed, however having documents stored in three different locations made it difficult to navigate. There was inconsistency with regards to completion and storage of residents’ records. Some were mostly in paper file and others on RIO. This can lead to confusion and should be addressed. The menus seen contained varied and nutritious meals, the choices were also available. The

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feedback about the menus was varied. Some staff said that lunches were nice; however dinners were “hit and miss”. Snacks and drinks were available throughout the day, at allocated times and at request. This was also confirmed by the feedback from staff and relatives. The activity programme was displayed on the wall in the hallway. Activities provided included: singing, arts & crafts, hand and nail care, relaxing music, film afternoons, reminiscence, doll therapy, chair exercise, cake baking, jigsaws, board games, Pat a dog, memory box etc.

Requirements and recommendations Standard 3.2 The manager must ensure that support plans are updated in line with needs and abilities assessment reviews. Timescale: Immediately Recommendation The manager should ensure that there is one consistent approach used to record and store residents records. Timescale: June 2017

Provider’s action plan Standard 3.2: All support plans have been updated as of 21/0217. Residents records have been audited against the record retention policy.

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9) Standard 7 - Management and Quality Improvement

OUTCOME: People have confidence that the systems in place support at the home the smooth running of the home. The registered manager is qualified and competent to manage the home. People are consulted about how the home is run and their opinions are taken into account. The home has an annual development plan that makes provision for the home to develop and improve.

Our decision: Partly compliant

Reasons for our decision The manager was recently appointed to the post. Prior to becoming a manager he was a registered nurse within the home. The manager was undertaking a level 5 QCF diploma. The manager explained that he did not have a handover from the previous manager, due to the manager leaving prior to his starting date. There was no evidence of the manager induction in his personnel file; this was also confirmed by him. The manager appeared to be keen to learn and develop his skills. However it was evident that he has been disadvantaged by the lack of formal induction. Policies and procedures were available to staff in the governments shared files. Policy and procedure files were also located in the staff room and were available to all the staff. The policy documents covered all the aspects of work including practical tasks, administrative tasks and

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legal/ethical responsibilities. However some of the policies and procedures in hard copy files were outdated and did not correspond to the policies online. If the manager chooses to have hard copies of the policies and procedures at the home, he needs to ensure that the files are updated regularly to reflect any changes made to the policies. The policy documents utilised by the home are written and reviewed centrally by the Department, not by the manager. Some of the policies and procedures were overdue the review. Regular service improvement group meetings took place, the latest recorded was held on the 25th of October 2016. Residents, relatives, staff and community members were encouraged to attend. The agenda covered outings, environment, fundraising and menus. The suggestion slips were available at the entrance, providing an opportunity for visitors to voice their opinions on how the home is run. However there must be more focused efforts to seek feedback from relatives, professionals and staff members on how the service is run, to feed into the annual report. The annual report was available for the inspector to scrutinise. It listed the achievements over the past year and the audits that have been conducted however did not provide a development/ improvement plan based on the outcomes of the quality assurance assessment. The records of regular team meetings were seen by the inspector. In addition to team meetings there were some records of housekeeping staff meetings as well as registered nurses meetings. The majority of the records were kept in line with the homes policy on record keeping and stored appropriately, dependent on the content, either in files in the office, in locked cabinets located in locked rooms or on the computer in areas where access is password and role restricted. However the inspector was told and shown that staff supervision as well as any performance monitoring records where kept in EMI service shared files that were accessible to all managers and registered nurses across all EMI services. This needs to be addressed immediately, as it is Data Protection issue. Policies and Procedures covered the residents’ right to access their records; however this information was not displayed in the home. The annual quality assessment in relation to the premises, staffing levels and skills, resident satisfaction and record making, care planning, risk assessments etc. was carried out by a Compliance and Finance Administrative officer. Although the report seen by the inspector covered a lot; there were several differences in findings between the quality assessment and the inspection. Also the quality assessment needs to be bi annual rather than an annual assessment. There was a provision in place for the residents to have their small amounts of cash to be kept safe. A recording system was in place and the money held was regularly checked and signed for. A financial policy was in place. However the manager explained that they did not support residents with finance management and this was usually done by social workers, families or Advocates.

Requirements and recommendations Standards 7.1 & 6.4 There must be a written induction and clearly identified process to assist and support the new manager to develop his management skills. Timescale: with immediate effect Standard 7.3 The manager needs to ensure that Policies and Procedures kept in the paper file correspond to the policies available to staff in the governments shared files. Timescale: April 2017

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Standard 7.4 Policies and Procedures need to be reviewed and updated within the timescales identified. Timescale: August 2017 Standard 7.8 The manager must ensure that an annual report introduces a written development/improvement plan based on the outcomes of the quality assurance assessment exercise, as well as list success of the service. Timescale: May 2017 Standards 7.10 and 7.12 The manager must ensure that supervision and any performance management records are kept in line with Data Protection Act 2002. Timescale: Immediate Standard 7.11 A written policy needs to be displayed in the home informing people of their rights to access their files and records at any time. Where access in restricted this is explained to individual. Timescale: April 2017 Standard 7.13 The service manager or the quality and performance improvement manager must conduct twice yearly visits to the home and assess in relation to the premises, staffing levels and skills, service user/representative satisfaction and record keeping. After which the reports must be produced and shared with the home manager for consideration when compiling the annual report for the service. Timescale: May 2017

Provider’s action plan Standard 7.1 & 6.4 There is a written induction for the manager commenced on 22/02/17, however the manager was an existing registered nurse working withing the area and is aware of the policy. Standard 7.3 There are no paper copies of policies in the unit except for complaints & safeguarding policies. All staff have access to policies and procedures via the shared files on the computer and are aware of how to access them. (completed 20/02/17). Standard 7.4 Any new or updated policies have been printed out and put in the read and sign folder for staff. All environmental risk assessments are up to date (completed 21/02/17). Standard 7.8 Gansey Manager will add this information into the next annual report and this will be checked by the Service Manager. Standard 7.10 & 7.12 The Service manager has issued Guidelines on how to store supervision records (completed 21/02/17). Standard 7.11. There is no policy relating to this, however I have gathered information on how a resident can access their files and records displayed on he resident information board (completed 21/02/17). Standard 7.13 The service manager frequently visits Gansey Unit. Staffing levels, skills mix service users satisfaction and

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records are discussed within the managers supervision. The quality and improvement manager has been asked to carry an audit of Gansey Unit.

ANY OTHER AREAS EXAMINED

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9) Standard 1.1 Statement of Purpose

Our decision Substantially compliant

Reasons for our decision The Statement of purpose was scrutinised by the inspector. The document was past the review date noted and in need for an update. The statement of Purpose covered all of the areas identified in the Regulation of Care (Registration) Regulations 2013 Schedule 3. However some information provided was out of date or inaccurate. The manager needs to ensure that the information provided is up to date and accurately reflects service provided.

Requirements and recommendations Standard 1.1 The manager must review the statement of purpose to ensure it is accurate and contains up to date information. Timescale: March 2017

Provider’s action plan Standard 1.1 At the time of the inspection there was an up to date statement of purpose in place. This has since been reviewed and sent to R&I on 23/02/17. It is displayed on the notice board

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9) Standard 4.8 4.9 - Complaints

Our decision Substantially compliant

Reasons for our decision The complaint policy and procedure, written in plain English was displayed on the notice board by the entrance to the Gansey unit. This policy contained the old Registration and Inspection Unit address. Upon looking at the homes policy and procedure files the inspector found several different versions of the complaint policy: one in date and containing all relevant information, one out of date, one that referred to a different home and didn’t contain all the required information. The manager needs to ensure that there is only one complaint policy in place and everyone is aware which policy to follow. Since the last inspection one complaint was logged. Actions and outcomes of the complaint were appropriately recorded.

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The compliment book contained a number of cards from relatives thanking the home for great care and atmosphere within the home.

Requirements and recommendations Standard 4.8 The manager needs to ensure that there is one clear complaint policy and procedure for everyone to follow. Timescale: March 2017

Provider’s action plan Standard 4.8. The complaints policy was updated on 17/01/17. A paper copy was put in the read and sign folder for staff. It is also displayed on the notice board by the entrance to Gansey Unit.

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9) Standard 4.1 - 4.4 Safeguarding

Our decision Partially compliant

Reason for our decision The inspector could not locate Isle of Man Inter-agency Safeguarding Adults, Adult Protection Policy 2016-2018 within the homes policy and procedure files, however it was accessible for all the staff via governments shared policy and procedure files. A Confidential reporting (Whistle blowing) policy was also available in the home. This policy was dated April 2009 and was due for review. Adult protection alert flowcharts were displayed in the staff rooms. The conversations with staff on shift evidenced their understanding of adult protection procedures. The staff training matrix was seen by the inspector. A number of staff members were overdue Adult protection refresher training. Also the training matrix stated that staff have Adult protection refresher training every three years, however the statement of purpose stated that the refresher training will be completed every 18 months.

Requirements and recommendations Standard 4.3 The manager needs to evidence that a copy of the Isle of Man Government Inter Agency Adult Protection Policy and Procedures 2016-2018 is read, understood and complied with by all staff at the home. Timescale: Immediate Standards 4.3 and 7.4 A Confidential reporting (Whistle blowing) policy must be reviewed and updated accordingly. Timescale: June 2017

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Standard 4.4 The manager must ensure that all staff members have Adult protection refresher training in timely manner. Timescale: June 2017

Provider’s action plan Standard 4.3 A copy of the Isle of Man Government InterAgency Adult Protection Policy and Procedures 2016-2018 was read & signed by all staff in November 2016. It has been reissued to all staff in February 2017. Standard 4.4 and 7.4 The Whistleblowing policy was read & Signed in November 2016. It has been reissued to all staff in February 2017. 4.4 All staff have now completed or have training dates booked for Adult protection.

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9) Standard 4.10 , 4.16, 4.17, 4.18, 4.19 Health and Safety

Our decision Partially compliant

Reasons for our decision The fire safety file was seen by the inspector. It contained: • A comprehensive fire risk assessment dated 08/02/16 and was due for review in February 2017; • Records of weekly fire alarm tests. There were several gaps in the records; • Record of fire drill. The only fire drill recorded since the last inspection was dated 29/06/16; • Records monthly fire extinguishers checks. There was a duplication of paperwork for fire extinguishers checks. After looking at both records, the inspector found that the extinguishers were not checked between 08/05/16-08/07/16 and 08/07/16-13/09/16; • Records of monthly emergency lights checks had some gaps and the latest recorded 13/09/16; • The fire training records for the staff team; • An up to date fire safety policy and procedures; • Personal emergency evacuation plans were in place for the residents; • Quarterly fire safety audit records; the latest recorded 10/10/16; • Annual fire safety audit, dated 13/04/16. Some visual portable electrical appliance (PAT) check records were seen by the inspector. However the visual check records found were limited to 6 appliances (2 items on 4/04/16; 2 items on 22/04/16; 2 items on 24/04/16). The was also a record of some PAT test carried out on 20/06/16; however it was difficult to understand what appliances were checked, were the appliances tested or just visual check was carried out, who carried out and recorded the checks. The manager needs to ensure all portable electrical appliance tests are carried out and recorded in compliance with current guidance and in line with their own policy.

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The manager could not locate an electrical installation report for the Gansey Unit. The Legionella risk assessment was reviewed in May 2016. The latest water report was dated 20/05/16. Gas safety inspection was carried out on 22nd of September 2016. Public and employer liability insurance certificate was in date and displayed at the entrance.

Requirements and recommendations Standard 4.10 The manager needs to ensure that weekly fire alarm tests; monthly firefighting equipment (including emergency lighting) checks and bi annual fire drills carried out and appropriately recorded. Carried over Timescale: Immediately Standard 4.16 All portable electrical appliance tests must be carried out and recorded in compliance with current guidance and instruction. Timescale: May 2017 Standard 4.16 Electrical installation certificate must be available at the time of inspection. Timescale: May 2017

Provider’s action plan Standard 4.10 All fire related assessments have been reviewed and updated. Estates Dept have been contacted regarding emergency lighting and the sprinkler system. Standard 4.16 There is a new PAT folder in place (completed 22/02/17). Estates Dept have been contacted for an up to date electrical installation certificate.

Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9) Standard 6 Staffing

Our decision Non-compliant

Reasons for our decision The inspector scrutinised six randomly selected staff files. All of the pre-employment documents (including evidence of DBS checks, references) were not available for the inspector to see, as these were kept at the Human resources office. Most of the files seen contained terms and conditions of the employment. Some of the files seen by the inspector contained supervision contracts. Three out of six files seen contained some induction evidence. However out of the three files: two contained incomplete and unsigned induction packs and one file contained fully

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completed induction pack that was not completed at the Gansey unit therefore it was irrelevant. As mentioned earlier in the report supervision notes were stored in the shared EMI area. It was evident that some supervision sessions took place. Whilst some staff records showed that they were on target to achieve the required number of 1 to 1 supervisions for the year, others were not. The manager needs to ensure that all the staff members receive the required number of supervisions to meet the Minimum Standards. Some of the staff files seen did not contain evidence of current Professional Development Plan. The training matrix was provided for the inspector to scrutinise. The inspector found that the training matrix: did not include all mandatory training records required by the minimum standards; some staff members were overdue various refresher training; some staff members did not complete all mandatory training. Staff rotas were seen by the inspector. The rota clearly identified the senior staff on shifts and any changes made were clear and easy to understand. Staff rotas were accurate and reflective of actual hours worked by individuals on each day. The manager was not able to evidence that regular written dependency assessment of residents needs was carried out. Although the overall dependency assessment template was shown to the inspector. There was no evidence that it has been completed since the last inspection, or that it was used to determine staffing levels and staff deployment.

Requirements and recommendations Standard 6.3 The manager needs to ensure that pre-employment check information for all the staff is available for the inspection. Timescale: April 2017 Standard 6.4 The manager must ensure that all new staff members have a written induction programme, which is followed and signed off by supervisor and inductee. Timescale: Immediately Standard 6.6 The manager must ensure that all staff members have regular 1 to 1 supervisions to meet the requirements of the standard. Timescale: Immediately Standard 6.7, 6.10 and 6.14 The manager must ensure that all staff members receive all mandatory training and identified refresher sessions required in timely manner. Timescale: August 2017 Standard 6.11 The manager needs to ensure that all staff members have an annual appraisal of their

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performance. Timescale: May 2017 Standard 6.18 Staffing levels and staff deployment need to be determined following a regular written dependency assessment of residents needs. The assessment needs to include reference to the layout of the home and the skills mix and experience of the staff team. Timescale: March 2017

Provider’s action plan Standard 6.3 Pre employement checks such as DBS & references are kept in the Human resources office. All staff who are due or overdue checks have been given an application form to complete and take to OHR. Standard 6.4 All new staff have an induction pack and they have been emailed and asked to bring them in once they have been completed and signed. Standard 6.6 All staff have a supervisor and have arranged dates for supervision. Standard 6.7, 6.10 & 6.14, All staff have access to the mandatory training matrix, training is discussed at their supervision. All classroom training is booked by Sian Doyle. The matrix is updated on a regular basis. Standard 6.11 All staff will have annual appraisal inplace by 31st March 2017. Standard 6.18 The Service manager completed the dependency levels for Gansey Unit on 23/02/17

Identified below are requirements made at previous inspections under Regulation of Care Act 2013 and progress to date:

No Regulation/Standards Requirement/date for compliance

Met/not met

1 Standard 2.1, 2.2 The manager should ensure that the environment of the unit is adapted and further developed, to ensure that a therapeutic dementia care environment is provided, that will allow residents to maintain their ability to function and will continually ensure improvements to their wellbeing.

Met

2 Standard 3.18 Where people do not manage their own medication, the support/activities of the staff members taking up this task are recorded.

Met

3 Standard 3.21 Numerous gaps were present on the MAR sheets where staff had not signed or entered a code. Medication should be administered and stored in compliance with the Royal Pharmaceutical Society of

Met

Requirements from previous inspection

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Great Britain – The Handling of Medicines in Social Care.

4 Standard 3.3 Part of the care plan concerns itself with the person’s known medical condition/s and documents and instructs the reader of the plan about how to support/maintain/improve the person’s medical condition.

Met

5 Standard 3.8 The plan set out personal goals and aims and details the support required to meet those personal aims. Timeframes are set and measured against the review process.

Met

6 Standard 3.9 The plan makes provision for people to follow their chosen faith where appropriate.

Met

7 Standard 3.12 When residents’ leisure interests and hobbies have been identified, instruction should be given for the reader as to how these should be maintained/encourages and recorded in the plan.

Met

8 Standard 4.10 Records should confirm that there is:

Weekly fire alarm checks; Monthly emergency

lighting checks;

Twice yearly fire drill

Not Met

9 Standard 1.1 The Statement of purpose should be reviewed.

Not met

10. Standard 2.15 If a resident is willing and able to carry out light domestic tasks, this should be documented in their care plan, along with the support they require to carry out these tasks.

Met

11. Standard 4.1 Environmental risk assessments should be regularly reviewed.

Partly met

12. Standard 4.9 Any complaint made and recorded should include what action was taken to investigate the complaint and if the complaint was resolved.

Met

13. Standard 4.10 The fire risk assessment should be reviewed.

Met

14. Standard 4.16 The home should evidence that PAT testing is being carried out.

Not met

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Identified below are recommendations made at previous inspections under Regulation of Care Act 2013 and progress to date:

No Standard Recommendations Met/not met

1 The home to use the Alzheimer’s Society book of activities to assist staff in finding activities of interest for individuals and groups.

Met

Please complete the provider action plan sections beneath each requirements and recommendations providing details of action taken (or to be taken) with timescale for each. The inspector would like to thank the management, staff and service users for their co-operation with this inspection. If you would like to discuss any of the issues mentioned in this report please do not hesitate to contact the Registration and Inspection Unit. Inspector: Egle Leadley Date: 17/02/2017

Good practice recommendations from previous inspection

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To: The Registration and Inspection Unit, 3rd Floor, Murray House, Mount Havelock, Douglas IM1 2SF From: Gansey Unit I / we have read the inspection report for the unannounced inspection carried out on 11th and 18th of January 2017 at the establishment known as Gansey Unit, and confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s). ☐

I/we agree to comply with the requirements/recommendations within the timescales as stated in this report. ☒

Please return the whole report which includes the completed action sections to the Registration and Inspection Unit within 4 weeks from the receiving the report. Or I/we am/are unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) ☒

There are a number of inaccuracies within the report as outlined below. Page 9 It is written, ‘ However it was evident that he had been disadvantaged by lack of formal induction’ this is a subjective opinion of the inspector and not based on fact. I had worked as a Senior Registered Nurse on the unit for 3 years and was aware of the processes and policies that are in place. Furthermore I was in post for 3 weeks prior to the inspection and a formal manager’s induction hadn’t commenced at this time. Page 12 The Statement of purpose was in date at the time of the inspection as it was due for review at the end of January 2017. Page 13 The Isle of Man Government Interagency Adult protection policy and procedures, was available in the safeguarding policy folder at the time of the inspection. Page 15 states that ‘ All the pre-employment documents (including evidence of DBS checks, references) were not available for the inspector to see as those were kept at the Human resources office’. Standard 6.3 states’ The manager needs to ensure that the pre-employment check information for all the staff is available for the inspection’. As stated these are kept in the Office of Human Resources. Inspector’s comments in regards to alleged inaccuracies:

The inspector’s comment in regards to lack of formal inductions was made because: the formal induction for the manager was not started at the time of the inspection, despite the manager being in post for 3 weeks prior to the inspection. Provider’s action plan states that the induction process started on 22/02/17, which is few months after the manager starting in the post. It is expected that the induction process starts at the same time as new appointment commences.

Statement of Purpose that was provided by the manager (emailed on 12/01/17) was dated June 2014 with the review date noted as June 2015. The inspector wrote the report based on evidence provided.

Although the inspector did not see the Inter agency Adult protection policy and procedure in the policy and procedure folder, it was noted in the report that it was accessible for all the staff via government’s shared policy and procedure files. The requirement made was

Provider’s comments/response

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not about having the hard copy of the policy, but evidencing that the policy is read, understood and complied with by all staff at the home.

The inspector acknowledged that all pre-employment checks were done and kept by the office of Human Resources. However in line with minimum standards the manager needs have evidence of these checks, hence the requirement.

Signed Manager EH Print name Eddie Humphreys Date Click here to enter text. Signed Click here to enter text. Print name Click here to enter text. Date Click here to enter text.

Action plan/provider’s response noted and approved by Inspector: Date: 10/03/17 Signature/initials EL