Inspection on 27/03/08 for Haighfield Nursing Home

This is the latest available inspection report for this service, carried out on 27th March 2008.

CSCI found this care home to be providing an Good service.

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

Other inspections for this house

Haighfield Nursing Home 22/02/06

Haighfield Nursing Home 02/12/05

Haighfield Nursing Home 11/02/05

Haighfield Nursing Home 05/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Haighfield Nursing Home 241 Wigan Road Standish Wigan Lancashire WN1 2RF Lead Inspector Marie Matthews Unannounced Inspection 27th March 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Haighfield Nursing Home DS0000005680.V360815.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. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haighfield Nursing Home Address 241 Wigan Road Standish Wigan Lancashire WN1 2RF 01942 821165 01942 200599 haighfield@m-a.co.uk 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) M & A Management Anne Ryan Casey Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 45 service users to include:up to 45 service users in the category of OP (Older People) 22nd February 2007 Date of last inspection Brief Description of the Service: Haighfield Care Home offers nursing and personal care and support for up to forty-five residents over the age of 65 years. It is situated on the main road between Wigan and Standish. Local amenities are a short drive away from the home. Haighfield is a purpose built home on four floors that has been extended. It offers thirty-five single rooms and five shared rooms; some rooms have en suite facilities and others have a hand basin. Bathrooms and toilets are in close proximity to accommodation and communal areas. The home offers two small patio areas at the rear of the home but outside garden space is limited. The external areas are well maintained and the grounds are well presented. Information about the services offered by the home is provided in the form of a service user guide and is available, with a summary of the most recent inspection report, to existing and prospective residents and their relatives. On the day of the inspection the weekly fees ranged from £460.00 to £554.00. Additional charges are made for hairdressing and for some of the planned trips. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection which the service did not know was going to take place, included a site visit to the home, which took place on 27th March 2008. The inspection process included looking at records, a tour of the home, discussions with the registered provider, registered manager, two staff and four residents who lived in the home. Information was also included from survey forms filled in by thirteen staff, nine visitors and eleven residents. The inspection also looked at things that should have been done since the last visit and a number of areas that affect people’s lives. There were thirty-six residents living in the home on the day of the inspection. What the service does well: Prospective residents and their relatives were given useful information about the services provided at Haighfield to help them make informed decisions about whether the home was suitable for them. Detailed information was collected about people before they were admitted to the home to determine whether they could be looked after properly. Every resident had a care plans that included details about how their health, personal and social needs would be met. Staff made sure that residents were looked after properly; comments from relatives included ‘staff are friendly dedicated and caring’, ‘they take care of mothers needs and are there 24 hrs a day’. There was evidence that residents were involved in decisions about the day-today routines; residents were consulted about their level of satisfaction of the service they received and their views and opinions had been sought at regular meetings. Staff approached residents and visitors to the home in a friendly but respectful manner and residents choices were respected. Residents said they enjoyed the activities or were able to spend time in their rooms if they preferred not to join in. Residents confirmed they were given choices and allowed to live the life they chose. There were many positive comments about the food including ‘the food is excellent’, ‘the food is smashing’, ‘we are given a good variety of food and given choices. I’ve never felt hungry’. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 6 The home was safe, clean, comfortable and well maintained; further improvements were planned to develop the home and provide a pleasant place for residents to live. One resident said there are ‘beautiful views to the countryside, it is always lovely and warm indoors’. The staff team were experienced, competent and provided in sufficient numbers to meet resident’s needs; checks were completed before staff started work to make sure they were suitable. Comments from people included ‘they do an excellent job’ and ‘staff are friendly and seem to have genuine care and respect for the residents.’ Records showed that systems were maintained and safety training was provided for staff to ensure that people’s health, safety and welfare was protected. What has improved since the last inspection? What they could do better: 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. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were given information about available services to help them to decide whether the home was suitable for them. Detailed information was collected about residents before they were admitted to the home to determine whether they could be looked after properly. EVIDENCE: Information about the services the home provided had been reviewed and updated so that people could make informed decisions about whether the home was suitable for them. The information was not yet available in other formats and was not available for reference in resident’s rooms. Information from resident and visitor surveys and from looking at records indicated people were given copies of their terms and conditions (contract) and Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 9 enough information about the service; this ensured people were aware of their rights whilst living at Haighfield. The care files of two recent admissions were looked at. It was clear that detailed information was collected about residents before they were admitted to the home to determine whether they could be looked after properly; however letters confirming that people’s needs could be met were not sent out. The registered manager said prospective residents would be given the opportunity to visit the home and meet other residents and staff prior to admission. Records showed that staff had the skills and experience to meet the needs of residents living in the home. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents personal and healthcare needs were met although systems to record people’s involvement in decisions about care needed to be improved; medication policies and procedures did not always support staff with safe practice and this could place residents at risk. EVIDENCE: Three care plans were looked at in detail. Care plans were developed from information obtained prior to admission and included details about how resident’s health, personal and social needs would be met. Staff had regularly reviewed the plans and there was evidence they had been updated when care needs changed; personal care needs and preferences were recorded in the care plan. There was little evidence of residents or their representative being involved in the development and review of the plan although they had been asked on admission if they would like to be involved and whether they would Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 11 like to have a copy of their plan. Visitors that were surveyed said they were kept up to date and consulted about changes to their relatives’ condition. Any risks to residents had been assessed and action to be taken to reduce or remove the risk had been recorded in the care plan. Records showed that resident’s health care needs were monitored and advice from other professionals had been sought if needs changed. One visitor said ‘they are good at looking after people’s physical well being’. Residents were provided with a range of specialised aids and adaptations to maintain their comfort and safety and to help them to maintain their independence wherever possible. Records showed that staff were trained in healthcare matters and were alert to any changes in resident’s condition. A key worker system allowed for one to one support for residents and their visitors. There was evidence that residents were involved in decisions about the day-today routines; residents were consulted about their level of satisfaction of the service they received and their views and opinions had been sought at regular meetings. The content of care plans was regularly checked to ensure resident’s needs were being met. The medication policies and procedures were incomplete and did not provide staff with clear and safe guidance that reflected current practice (see also standard 33). The registered manager said these were due for review and advice was given to assist with this process. Procedures for the receipt, recording, storage, handling, administration and disposal of medicines were in the process of being reviewed but needed to reflect current practice to ensure medicines were not mishandled. Other procedures needed to developed or updated to provide staff with safe guidance included - leave/visits, self administration, transcribing, homely remedies, oxygen, drug error, PRN medication, covert administration, verbal changes, non- prescribed medication and controlled drugs. There were no residents looking after their own medicines although all rooms were provided with lockable storage for safe storage of their medicines. Records were clear and accurate although there were gaps on the MAR where it was unclear whether prescribed external medicines (creams) had been administered and it was recommended that the records of disposal should be witnessed to reduce the risk of mishandling. Clear protocols were not in place to support staff in their decisions to administer ‘as needed’ or ‘PRN’ medicines. Controlled drugs were checked at random and were found to be accurate. Storage areas were appropriate and secure and systems were subject to regular checks to ensure medicines were managed safely. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 12 Observation showed that staff approached residents and visitors to the home in a friendly but respectful manner and residents choices were respected. Residents said they received the care and support needed and that staff listened to and acted on what they said. One resident said she had recently been visited by her GP in the privacy of her room. One member of staff commented ‘staff are aware of privacy and dignity at all times’. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents take part in activities that suit their diverse lifestyles and maintain their interests. Residents received a healthy, varied diet that was suited to their individual preferences and requirements. EVIDENCE: There was an activity co-ordinator who supported residents to be involved in meaningful activities of their choice. Records showed that a range of suitable activities and entertainments were available that met most residents individual interests, diverse needs, capabilities and preferences. Residents said they enjoyed the activities or were able to spend time in their rooms if they preferred not to join in; one lady said she wasn’t interested in the activities but was content to spend time in her room watching TV. One resident said she ‘enjoys bingo, quizzes and other activities, particularly the singing and concerts’ another commented that they enjoyed ‘the bingo, quizzes, tea dances, Halloween party and firework display’. One resident said ‘there is plenty going on’. Another was given help to arrange visits to a relative’s home. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 14 People’s spiritual needs were met by regular visits from the local clergy although one survey indicates this did not apply to all residents and the residents own minister visited. Meetings had been held to discuss resident’s suggestions, choices and preferences concerning various aspects of the day-to-day running of the home. Residents and their relatives had completed social history forms that detailed past employment, family members, preferences and routines and important dates; this would help staff to plan suitable activities. Visitors were made to feel welcome and could visit in any area of the home. Residents were given choices in various aspects of their daily routines; one member of staff said ‘residents are allowed to deal with choosing own clothes, meals and drinks’. Residents confirmed they were given choices and people said they were allowed to live the life they chose. The menu offered a choice at each meal and was displayed in the dining areas; records supported that choices were offered and other alternatives to the menu were provided although the teatime choices had not always been recorded. On the day of the key inspection the lunchtime meal looked nutritious and appetizing and residents said they had enjoyed it. There were many positive comments about the food including ‘the food is excellent’, ‘the food is smashing’, ‘we are given a good variety of food and given choices. I’ve never felt hungry’ and ‘I enjoy the food and have put on weight since coming here’. The dining areas were bright and pleasant and tables were attractively set. Staff were seen giving appropriate assistance to residents who needed support with their meals. One resident said birthdays and special occasions were celebrated; records showed that special diets were catered for. Information from the survey indicated that suppers were served too early and residents had to wait a long time until breakfast; this was discussed with the registered manager who said suppers were served throughout the evening and food was always available for any snacks required during the night. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 15 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People knew how to complain and staff had a good knowledge and understanding of what abuse was, thereby reducing the possible risk of harm to residents. EVIDENCE: The complaints procedure was not easily accessible to people; however from discussion and survey information it was clear that people knew how to complain and were satisfied that their complaint would be dealt with appropriately. The registered manager said there had been two complaints in the past twelve months; records supported that complaints were responded to according to procedure. The policies and procedures for safeguarding adults were out of date and did not give clear specific guidance for staff (see also standard 33); however staff were aware of action to be taken if they suspected abuse and training had been provided for most staff to ensure they were able to recognise abuse and respond appropriately to protect residents from harm. The registered manager said the procedure was due for review to provide clear guidance for staff. There had been one safeguarding referral in the past twelve months and this had been discussed openly with the appropriate agencies. The whistle blowing Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 16 and dealing with aggression policies and procedures were also due for review (see standard 33). There were individual assessments to support any decisions to use restraint such as bed rails and these had been discussed with residents and their representatives and kept under review to ensure they are used appropriately. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 17 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, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was safe, clean, comfortable and well maintained and further improvements were planned to develop the home and provide a pleasant place for residents to live EVIDENCE: From a tour of the building it was clear that the home was well maintained both internally and externally and met residents needs in a safe, comfortable and homely way. There was a development plan that supported ongoing and future improvements; at the time of the inspection visit work was underway to respond to recommendations made at the last key inspection. The fire service and environmental health officer had visited recently; there had been no concerns around safety. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 18 Communal areas were bright, comfortable and well furnished. Outdoor space was limited although grounds were tidy and attractive. One resident said there are ‘beautiful views to the countryside, it is always lovely and warm indoors’. There were sufficient toilets and bathrooms around the home and within easy reach of bedroom and communal areas although some of these were dimly lit and in need of redecoration as part of the refurbishment plan. The manager was advised that a bathroom door lock was in need of attention. Residents were provided with a range of specialised aids and adaptations to maintain their comfort and safety and to help them to maintain their independence wherever possible although there were no grab rails on the long corridors; residents had requested that seating was provided and the registered manager was looking into this. All rooms were provided with an accessible call facility. Wheelchairs were currently being stored in an empty room. Resident’s rooms were clean and bright and furnished to a good standard; most had been personalised with treasured possessions. Doors were fitted with locks and rooms had lockable storage space to help residents maintain their privacy. However one resident’s room had a torn carpet that could create a trip hazard and a mattress in another resident’s room was badly stained; these were brought to the registered manager’s attention. Residents and relatives said the home was always clean, bright and odour free. A fan in a resident’s bedroom was in need of cleaning to reduce the risk of cross infection. One visitor commented ‘the home is kept very clean and always smells fresh’. The laundry system was efficient and appropriate equipment was provided that met resident’s laundry needs. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team were experienced, competent and provided in sufficient numbers to meet resident’s needs. A robust staff recruitment process was in place in order to protect residents from possible harm although procedures did not support good practice. EVIDENCE: On the day of the inspection there were sufficient staff on duty. One comment from a visitor was ‘they sometimes seem to need more staff’ another from a staff member was ‘sometimes short staffed at weekends but every attempt is made to find cover’. However all residents surveyed said that staff were available when they needed them. Staffing rotas were clear and staff were organised into teams to be able to meet people’s needs on all floors. The recruitment procedure was not up to date and did not reflect current practice; the registered manager said it was due for review. Two staff files were looked at. A safe recruitment process had been followed to ensure that residents were protected from harm. Staff confirmed that a safe recruitment process had been followed and that checks were completed before they started employment. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 20 Records showed that staff had received appropriate training and support to help them to understand the needs of residents in their care. More than half of care staff had achieved a recognised qualification in care and this would help them to meet residents’ needs. Staff said they received a range of training that kept them and others safe. Staff meetings were held regularly and minutes were recorded; staff said they were able to express their opinions of the service and were kept informed. Comments from visitors about staff were very positive; comments included ‘staff are friendly dedicated and caring’, ‘they take care of mothers needs and are there 24 hrs a day’, ‘staff are always busy but never too busy too help people’, ‘they do an excellent job’ and ‘staff are friendly and seem to have genuine care and respect for the residents.’ Comments from residents included ‘Staff are very nice and helpful’ and ‘staff are excellent’. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 21 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, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefited from a well managed home and their health, safety and welfare was promoted and protected although policies and procedures did not support staff with safe practice. People were involved in decisions about how the home was run. EVIDENCE: Ann Ryan Casey is the registered manager; she is a registered nurse and has the Registered Managers Award that will assist her with her management role. People made positive comments about her contribution to improving the home; these included ‘she is very supportive’ and ‘she is a good listener’. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 22 A number of systems were in place to monitor all aspects of the quality of the home and whether peoples’ needs and expectations were being met. The home was also monitored by external agencies that ensured standards were maintained. The registered provider visited the home regularly and the registered manager said she was ‘very well supported’; she was also able to meet with registered manager from another home within the group to discuss any issues or areas of concern. The AQAA had been completed in detail and showed that senior management recognised the areas in need of improvement. Financial records for two residents were checked; records showed that resident’s finances were safeguarded by the systems and record keeping. Policies and procedures had been reviewed annually, however many of these did not reflect current practice and did not provide safe guidance for staff. The registered manager said they were all due to be reviewed. Records and discussions with staff confirmed that regular one-to-one supervision and support sessions had taken place; this monitored whether staff were meeting residents needs and would identify any further training needs. Records showed that systems were regularly maintained and safe and safety training was provided for staff to ensure that people’s health, safety and welfare was protected. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 23 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 3 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 X 2 X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 24 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. 1. Standard OP7 Regulation 15 Requirement Residents and/or their representatives must be involved in the development and review of their care plans. The medication policies and procedures must provide clear and safe guidance for staff in all aspects of medicine management. The safeguarding adults procedures must provide clear and specific guidance for staff. The recruitment procedure must be reviewed to provide safe guidance. All policies and procedures must be reviewed to support staff with safe practice. Timescale for action 19/05/08 2. OP9 13 19/05/08 3. 4. 5. OP18 OP29 OP33 13 13 13 19/05/08 19/05/08 19/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 25 1. 2. 3. OP1 OP4 OP9 Residents should be given a copy of the service user guide to use as reference. Written confirmation that needs can be met should be sent to residents or their representatives prior to admission There should be protocols to support staff with the administration of ‘PRN’ or ‘as needed’ medicines. Administration of prescribed external medicines should be recorded. 4. 5. 6. 7. OP15 OP16 OP21 OP24 Records of medicines for disposal should be witnessed. Records of meals served should be completed in full to evidence residents are given a choice at each mealtime. The complaints procedure should be easily accessible to residents and their visitors. The lock on the shower room door should be repaired to ensure protection in case of fire. The torn carpet in a resident’s bedroom should be replaced to prevent any trip hazards. The soiled mattress in a resident’s bedroom should be cleaned or replaced. The fan in a resident’s bedroom should be cleaned. Haighfield Nursing Home DS0000005680.V360815.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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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