Key inspection report CARE HOMES FOR OLDER PEOPLE
Conifers Nursing Home 158 Manchester Road Chorlton Manchester M16 0DZ Lead Inspector
Val Bell Key Unannounced Inspection 16th June 2009 08:00
DS0000021639.V377044.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 2 Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Conifers Nursing Home Address 158 Manchester Road Chorlton Manchester M16 0DZ 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) 0161 881 2514 0161 862 9635 Dr V.K. Trehan Mrs S Trehan Manager post vacant Care Home 21 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (21) of places Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing: Code N, to service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category: Code OP Dementia - Code DE (maximum number of places 5) The maximum number of service users who can be accommodated is: 21. Date of last inspection 3rd July 2008 Brief Description of the Service: Conifers Nursing Home is registered to provide accommodation and nursing care for up to 21 older persons. It is part of a family run business, which includes one other nursing home and a residential home. The registered provider is Dr. V Trehan. The home is situated on a busy main road in the Chorlton area of Manchester. It is close to local facilities, bus routes and the city centre. Accommodation is provided on two floors, served by a passenger lift and the home is accessible to people who use a wheelchair. Bedroom accommodation is on the ground and first floor. There are 7 single bedrooms, 2 of which offer en-suite facilities and 7 double bedrooms. All rooms offer the facility of a wash hand basin. There are 2 lounges and one lounge/ dining area. The paved patio to the side and the rear of the home is accessible via patio doors and a ramp. Beyond the patio is a large garden area, which has benefited from the recent addition of raised decking with shade being provided by a gazebo constructed in wood. The garden and patio are separated by a low wall containing raised flower beds that are cultivated by people living in the home. The current charges for fees range from £388.00 to £452.50 per week.
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DS0000021639.V377044.R01.S.doc Version 5.2 Page 5 Information about the home can be gained through contacting the registered provider, Dr V Trehan or the registered manager Mrs Sarojanamma Adala. The CSCI inspection report is available at the home and through the CSCI web site. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes.
This was a key inspection, which included a site visit to the home by two inspectors. The visit was unannounced which means the manager was not informed beforehand that we were coming to inspect. During the visit we spent time talking to people living in the home, a visiting relative, the cook, three members of staff on duty, the manager and the home’s care manager who provides advice regarding care and management issues. An Annual Quality Assurance Assessment (AQAA), which is a selfassessment document, had been completed and returned to the Commission prior to our visit. We also received completed satisfaction surveys from staff employed by the home. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. What the service does well:
Thorough pre-admission assessments are undertaken before a person moves into the Conifers. This ensures that their needs will be met and that the home will be a good place for them to live. Management and staff treat people as individuals and respect their rights to make choices and decisions and to lead their lives in a private and dignified manner. People living in the home are provided with regular opportunities to express their views on the quality of the service being provided and suggestions for improvement inform the future development of the service. This has been evident in improvements made to meals and activities. Staff are regarded highly by the people living in the home. One person told us that staff are kind and caring. This was confirmed during our observation of interactions between staff and the people they cared for. Several staff were observed to offer reassurance to people experiencing confusion and to take time to provide assistance with finding their way around the home. The manager and staff placed a high priority on health and safety within the home. Risks were appropriately assessed and were being managed well. Similarly, robust procedures were in place to check the suitability of staff applying to work in the home. This afforded good protection to the welfare of the people accommodated. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection?
Significant improvements had been made since our last visit. The implementation of regular meetings and ongoing discussions had positive outcomes for people using this service. We found evidence that the people accommodated in the home had been involved in their care planning and were regularly being consulted about such choices as meals, activities and their wishes in relation to religious, cultural and social needs. Assessments had been undertaken for people who lacked the capacity to make independent decisions. These assessments protect individual’s right to have decisions made in their best interests. Care records provided evidence of prompt referrals to health care professionals where concerns had been identified. The manager made sure that nursing and care staff had clear guidelines on what they must do to follow health care professionals’ advice. This action had significantly improved personal and healthcare outcomes for people living in the home. The medication system used by the home had been improved by keeping accurate records of all medication disposed of. The two cooks employed by the home had achieved level 1 National Vocational Qualifications in catering since our last visit to the home and were working towards this qualification at level 2. Menus provided evidence of a range of nutritionally balanced meals, including special diets and meals that met people’s religious and cultural needs. Several people living at the home need some support in managing their personal spending money. The management and staff team help people by looking after some of their money and shopping for personal items. The records of these transactions were clear and accurate and there was a regular monitoring system in place to make sure that records were being maintained accurately. Another area that the management team needed to improve was in the way that they monitored the quality of people’s experiences, the services provided and the systems that were in place to operate the home. The system for assessing quality had been improved to provide evidence that people were regularly being asked about their views of the home. Where suggestions for improvement had been expressed action had been taken in the best interests of people using the service. A visiting relative told us that the service had improved since the new manager had been appointed. He praised the manager’s personal qualities and said that he was good at making sure the needs of people living in the home were being met. This was evidence of effective leadership and communication.
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DS0000021639.V377044.R01.S.doc Version 5.2 Page 8 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Conifers Nursing Home DS0000021639.V377044.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 Conifers Nursing Home DS0000021639.V377044.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are robust systems in place to assess peoples’ needs, which ensures that the service provided is based on personal needs and preferences. EVIDENCE: We looked at the information pack that was available for people enquiring about this home. It contained the Statement of Purpose and important information about the service and facilities that the home provides. The Statement of Purpose detailed the qualifications of staff working in the home. This included a statement about the current manager being registered with the
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DS0000021639.V377044.R01.S.doc Version 5.2 Page 11 Care Quality Commission. This statement should be removed from the document as the current manager had not submitted an application to be registered with the Commission at the time of our visit. We looked at the process for confirming that the needs of people moving into the home are able to be met. Three people living in the home had been jointly assessed by the primary care trust and social services and copies of these assessments were held in the individual’s care records. The manager explained that he also visits the person to undertake an in-house assessment of need. It was pleasing to see that particular attention had been paid to assessing the religious and cultural needs of individuals and in making sure that any risks to the safe delivery of care were identified. This indicated that the service places importance on respecting the individuality of each person accommodated in the home in order to meet their needs in a person-centred manner. This was a robust process of needs assessment and was identified as evidence of best practice. This home does not offer an intermediate care service. Conifers Nursing Home DS0000021639.V377044.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the Conifers have their needs met and their care is provided in a manner which protects their privacy and dignity. EVIDENCE: Significant improvements had been made to the care planning system since our last visit. The two care plans we examined contained clear guidance on what staff must do to meet each person’s individual needs in a private and dignified manner. Similarly, risks had been assessed and written guidelines informed staff of the action they must take to keep each person safe. The care plans and risk assessments had been reviewed each month and updated where
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DS0000021639.V377044.R01.S.doc Version 5.2 Page 13 necessary. It was pleasing to see that relatives had been informed in writing of any changes made and they were invited to look at the care plan when they next visited to make sure they had up to date information about the care being provided. A relative we spoke to praised the care that his mother received. He said, ‘Staff are very caring and the new manager is a lovely man. He communicates well and lets me know of any concerns he has about my mother. The service has definitely improved since he was appointed.’ We saw written evidence of prompt referrals to health care professionals when concerns had been raised about individual’s health and welfare. Following such appointments the manager had written down clear instructions to ensure that staff consistently followed the advice given by health care professionals. This was identified as evidence of best practice in effective communication and continuity of care. Mental Capacity Act legislation had been implemented by assessing each person’s capacity to make important decisions related to the care and support they received. However, this information should be related directly to the care plans by recording how decisions will be taken and by whom. For example, we spoke to a relative who was visiting his mother. He told us that staff always consulted him on important decisions and issues relating to his mother’s care. This had not been made clear in the care plan. We asked the manager if people who had no relatives involved in their care had access to advocacy services. The manager told us that he had been in touch with an organisation that provides advocates, but had been told that these were in short supply at the moment. In these circumstances it is particularly important that there is written evidence that decisions are being taken in the best interests of people using this service. We looked at the system in place for administering medication to three people living in the home. Accurate records were held of all medication received into the home and the quantity of medicine disposed of. Each person had an accurate record of the medication which staff had administered to them and all medicines were stored in a secure clinic room. The temperature of this clinic room was being monitored on a daily basis and records showed that occasional temperatures reaching 27.5ËC had been recorded. This was above the recommended operating temperature for medication storage. The manager was aware that if excessive temperatures were to continue, then remedial action must be taken to bring the temperature down to recommended levels. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the Conifers receive the support they need to live their preferred lifestyle. EVIDENCE: Significant progress had been made since our last visit on extending the range of activities available to people living in the home. Current activities were posted on a notice board and records detailed the outcome of peoples’ experiences of participating in group and individual activities. It was evident that every effort was being made to provide stimulation and interest for people on an individual basis, according to their preferences. One person said, ‘Staff
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DS0000021639.V377044.R01.S.doc Version 5.2 Page 15 know I love Irish music and they always ask me if I want this on after lunch.’ We observed this taking place on the day of our visit. The home had recently employed an activities co-ordinator who arranges both group and individual activities each day during the week. Birthdays, religious feast days and special events were regularly celebrated with parties, theme days and visiting entertainers and day trips were provided during the summer months. The home operates a flexible visiting policy. People have the choice of receiving visitors in one of the lounges or in the privacy of their own bedrooms. A person visiting his mother told us that he is always made welcome in the home and likes to meet with his mother in the quiet lounge. He praised staff for the way they keep him informed about his mother’s progress. Since we last visited the two cooks employed by the home had been enrolled on National Vocational (NVQ) courses in catering. Both cooks had achieved a level 1 NVQ and were currently working towards level 2. One of the cooks had been nominated as ‘Student of The Year’ by the college and the home proudly displayed a photograph of her receiving this award. In conversation with the cook on duty at the time of our visit, it was evident that she had used her training and development to implement significant improvements to the catering provided by the home. Menu’s consisted of a range of nutritionally balanced meals, including cultural and special diet options. It was pleasing to learn that the manager had taken delivery of a set of food moulds to improve the presentation of meals for people on soft and pureed diets. This provided evidence of a person-centred approach in meeting the nutritional needs and preferences of people living in the home. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good systems are in place to enable people to express their concerns and have them dealt with, to protect their human and civil rights and safeguard them from harm. EVIDENCE: This home had an accessible policy and related procedures for dealing with complaints within clearly specified timescales. Since our last visit two complaints had been investigated and records provided evidence that people had received timely responses to their concerns. The home had also received cards and flowers from people thanking staff for the care they provided. One person wrote, ‘We would just like to thank you for your outstanding care during (our relative’s) stay with you. It is very much appreciated.’ The manager and staff had responded well to the requirements of Mental Capacity legislation, by undertaking assessments of people’s capacity to make decisions. We recommend that this be further developed in order to link these
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DS0000021639.V377044.R01.S.doc Version 5.2 Page 17 assessments into specific care plans by clearly identifying exactly what decisions people can or cannot make. For example, a person may not have the capacity to make decisions in relation to spending money, but may retain the capacity to make decisions about their preferred diet, what clothes to wear, when to get up or go to bed. This will vary from person to person and should be clearly detailed in individual’s care plans. For example, we spoke to a relative who was visiting his mother. He told us that staff always consulted him on important decisions and issues relating to his mother’s care. This had not been made clear in the care plan. Similarly, when decisions need to be made on behalf of people living in the home, care plans should record how those decisions will be taken and who will be responsible for doing so. We asked the manager if people who had no relatives involved in their care had access to advocacy services. The manager told us that he had been in touch with an organisation that provides advocates, but had been told that these were in short supply at the moment. Detailed records on decision-making are an important source of written evidence that decisions are being taken in the best interests of people using this service. We asked three staff about what they do to protect people living in the home from harm. It was evident from their responses that they had a clear understanding of the procedures for safeguarding vulnerable adults from harm. Training records provided further evidence that safeguarding training had been provided to staff working in the home. We observed staff interacting with the people they cared for and it was pleasing to see them encouraging people to maintain freedom of movement while at all times continuing to monitor their safety in a discrete manner. Several staff were observed to offer reassurance to people experiencing confusion and to take time to provide assistance with finding their way around the home. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in suitably adapted, clean, comfortable and very pleasant surroundings. EVIDENCE: We undertook a tour of the home to assess safety, cleanliness and hygiene in the environment. We looked at three bedrooms and internal and external
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DS0000021639.V377044.R01.S.doc Version 5.2 Page 19 communal space. The home had been suitably adapted to meet the mobility needs of the people accommodated. Considerable refurbishment had taken place since our last visit. The refurbishment had enhanced and extended the range of environmental facilities accessible to people living in the home. Particular attention had been paid to ensuring that all parts of the home were safe, clean and hygienic. During our visit several people were able to take advantage of the nice weather by having their lunch in the newly landscaped garden and staff had made sure that each person was shaded from the hot sun. A visitor to the home told us that he was pleased with the refurbishments as these had made the home a pleasant and comfortable place for his mother to live. Lounge areas were light and airy with a homely and relaxed atmosphere. Further improvements were planned to ensure that the excellent standards achieved would be maintained. The home’s laundry provided an efficient service for people living in the home and procedures for the control of infection were being followed by the staff employed. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing arrangements, recruitment and training ensure that people are cared for and supported safely. EVIDENCE: There were sufficient staff on duty when we visited the home and the current weeks rota provided evidence that these staffing levels were being maintained. We looked at the recruitment and training records for a member of staff that had been employed since we last visited. The required pre-employment documents had been obtained and saved in her personnel file. This provided evidence of a robust recruitment system that ensured that new staff were suitable to work with people living in the home. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 21 Three staff spoken to confirmed that they had access to regular and relevant training and training and development records provided further evidence of this. The new member of staff had undergone an induction process following her appointment. The content of the induction was consistent with those specified by ‘Skills for Care’. Staff also confirmed that they receive regular supervision and ongoing support from the manager and they were confident that they could request more training if they felt they needed it. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Conifers is being managed in the best interests of people accommodated in the home. EVIDENCE: Since we last visited a suitably qualified and experienced manager had been appointed to be in day-to-day charge of the home. People living in the home
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DS0000021639.V377044.R01.S.doc Version 5.2 Page 23 praised the manager and a visitor to the home commented that the manager was good at communicating and making sure that people’s needs were being met. Staff told us that they had a good relationship with the manager and that he was supportive and treated them fairly. This service had achieved the Investors in People Award. A system for assessing the quality of the service provided was in place at the home. This included regular audits of systems, policies and procedures and accessing the views of people using the service and their representatives. Comments from recent satisfaction surveys included, ‘I find (my relative’s) care is very good and staff very friendly’ and ‘All staff are respectful and friendly.’ The personal finances belonging to people living in the home are managed either by their relatives or the local authority. There is a system in place to assist people with managing small amounts of personal spending money. Accurate and up to date accounts are held for this and all money managed in this way is held securely in the home’s safe. We examined a sample of health and safety records and found these to be accurate and up to date. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The term ‘registered manager’ should be removed from the Statement of Purpose to accurately reflect the status of the newly appointed manager. The Statement of Purpose must provide accurate information to people using this service. Care plans should clearly identify exactly what decisions people can or cannot make. Where decisions need to be made on behalf of people living in the home, care plans should record how those decisions will be taken and who will be responsible for doing so. 2. OP17 Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk
We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Conifers Nursing Home DS0000021639.V377044.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
