Inspection on 08/01/08 for Seven Hills Nursing Home

This is the latest available inspection report for this service, carried out on 8th January 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

Seven Hills Nursing Home 11/11/05

Seven Hills Nursing Home 21/06/05

Seven Hills Nursing Home 23/02/05

Seven Hills Nursing Home 27/07/04

Seven Hills Nursing Home 10/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

CARE HOMES FOR OLDER PEOPLE Seven Hills Nursing Home 17 Cherry Tree Road Nether Edge Sheffield South Yorkshire S11 9AA Lead Inspector Sue Turner Key Unannounced Inspection 8th January 2008 08:30 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 Seven Hills Nursing Home DS0000021811.V355721.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. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seven Hills Nursing Home Address 17 Cherry Tree Road Nether Edge Sheffield South Yorkshire S11 9AA 0114 255 3023 0114 255 3023 none 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) Beech Lodge Ltd Anna Frans Melisse Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2006 Brief Description of the Service: Seven Hills is a 24-bedded nursing home for older people with elderly mentally infirm needs. It is a converted villa with a purpose built extension. It is a small privately owned care home. The home is situated in the residential area of Nether Edge. It lies within easy access of a regular bus service and Sheffield City Centre. There are stairs and a lift to access the two floor areas. There is a car park to the front of the building. The weekly fees are from £468 to £519. The manager explained that the fees are charged according to the dependency levels of the individuals and also according to the source of funding. Additional charges included newspapers, hairdressing and private chiropody. Up to date information with regards to the service was available so that people and the relatives were able to make an informed choice about the home. A copy of the incorporated Statement of Purpose and Service User Guide was on display at the entrance next to the signing in book so that visitors were able to read about the home. Information about how to raise any issues of concern or make a complaint was also on display in the entrance hall. Seven Hills Nursing Home DS0000021811.V355721.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 star. This means that the people who use this service experience good quality outcomes. This was an unannounced key inspection carried out by Sue Turner regulation inspector. This site visit took place between the hours of 8.30 am and 4:45 pm. Joanne Woodward is the manager and was present during the visit. The provider is Saleem Hasan, who was also present during the site visit. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people staying in the home, their relatives and any professionals involved in peoples care. The Commission for Social Care Inspection (CSCI) received two questionnaires from people using the service, one from a relative and two from professionals. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home and check the homes policies and procedures. Time was spent observing and interacting with staff and people. Seven staff, three relatives and one person living in the home were spoken to individually. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in July 2006. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 6 What the service does well: People living in the home said that the care they were receiving was good. They made comments such as: “Staff are caring and helpful”. “Staff are very kind”. “I am very comfortable here”. Comments received from questionnaires and from talking to relatives were in the main positive and included: “The home is clean and the staff are caring”. “I’m always made welcome, they’ve got nothing to hide”. “Staff are very co-operative”. “Staff deal with people’s needs in an individual way”. “Staff talk to people with tenderness, kindness and humanity”. “People living here love conversation and they get plenty of that”. Health professionals said: “The home meets the client’s needs and respects difference and choice”. “From the review I have completed the home worked with the client, looking at their needs and choices”. “The home provides compassionate care and respond appropriately to health care needs”. The inspector observed that people were well dressed in clean clothes and had received a very good standard of personal care. Care plans were in place for all. These were well set out and easy to read. They set out all aspects of personal, social and health care needs and recorded the staff action required to ensure all identified needs were met. People’s health care was monitored and access to health specialists was available. Staff were observed being very respectful towards people. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 7 People said that they had a choice of food and that the quality of food served was “well cooked with just the right amount” and “I always enjoy my food”. There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. The home was clean, tidy and extremely fresh smelling. Relatives said that the home was always kept “immaculately clean” and “there are never any unpleasant odours”. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. Records within the home were stored securely, to safeguard confidentiality. Health and safety procedures were identified and carried out, and systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? All of the requirements made at the previous inspection had been actioned, the provider, manager and staff are commended for this. A new medicine trolley had been purchased to ensure that people’s medications were securely stored. The outdoor area had been made suitable for the use of people and their friends and relatives. Shrubs and vegetables had been planted which the staff said would benefit people by them becoming involved in their care and attention. A rolling programme of refurbishment and redecoration was underway. Communal areas and people’s bedrooms were being decorated and new carpets fitted. New crockery had been purchased and was ready for use when the new dining room furniture was put in place following the redecoration of the dining area. Towels and bed linen had been replaced and these were seen to add to the comfort of people. Staff supervision took place, to support and give guidance to staff on an individual basis. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 8 What they could do better: People’s health and welfare would be further protected by: • Qualified staff making sure that Medication Administration Records (MAR) sheets are fully completed and signed at the time of medication administration. Ensuring that codes on MAR sheets are used consistently. Staff not being permitted to work at the home until they have a completed Criminal Records Bureau (CRB) check. Recruitment procedures being carried out to comply with the Care Homes Regulations. Fire system checks carried out are fully recorded. Substances that could be hazardous to health are kept locked away at all times. • • • • • 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. Seven Hills Nursing Home DS0000021811.V355721.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 Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 is not applicable to this home. People who use 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 home provided sufficient updated and relevant information to inform people about their rights and choices. Pre admission information ensured the home was able to meet people’s health, social and care needs. EVIDENCE: The homes had an incorporated Statement of Purpose and Service User Guide. This was available in the entrance hall for anyone visiting the home. It included useful information about the home and the services offered. It had been updated accordingly. Professionals and staff from the home, prior to admission taking place, assessed people. This either took place at Seven Hills or at people’s own Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 11 homes if they preferred. The manager said that assessments in hospitals were also possible if needed. The manager completed a pre service assessment to assess that the home was able to meet each person’s individual needs. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use 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’s care needs were documented in the care plans. Individual needs were met. In the main, medication procedures protected people’s health and welfare. Staff promoted people’s privacy and dignity. EVIDENCE: Three plans of care were checked. These contained specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. Staff were aware of the contents of care plans and were knowledgeable about people’s individual needs. The care plans identified that a range of health professionals visited the home to assist in maintaining people’s health care needs. Staff said that GP’s, Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 13 dentist, opticians and chiropodists visited the home as requested. Evidence of this was seen in people’s records. Relatives said they were aware that they could be involved in drawing up and reviewing the care plans. Some relatives chose to be involved, whilst others said they were happy be involved in an informal way, by speaking to staff at each visit. This kept them up to date with any changes to the care plan. Minutes from the relatives meeting confirmed that relatives had been reminded that they were able to look at the care plans, at any time, should they wish. Staff were updating risk assessments and care plans on a monthly basis. Relatives said: “If dad is ill the staff are very efficient in getting the doctor to come out and prescribe the appropriate medication”. “Mum has thrived since she came here, she is happier and healthier”. Medicines were securely stored in a locked trolley, which was kept in a medical room when it wasn’t in use. Medications were supplied by the pharmacists in monitored dosage. Only qualified nurses administered medications. There were records of all medicines received and disposed of by the home. There was evidence that managers were auditing medication administration procedures, however there were some gaps in MAR sheets. MAR sheets had codes that could be used to explain why a medication may not have been given. These codes were not used consistently. Sometimes a code was used and at other times the MAR sheet was left blank. This was the same for medications that were prescribed on ‘ only when needed’ basis. Following the site visit the provider confirmed in writing that a meeting had been held with the manager and all qualified staff. Staff had been made aware of the medication issues and closer monitoring had been put in place. Staff spoken to were aware of the need to treat people with dignity and respect and were observed interacting in a friendly and pleasant way. Two professionals were asked if the service respected people’s privacy and dignity. One answered “always” and the other said “usually”. Relatives said: “People always look well cared for, the gents are clean shaven and the ladies are well groomed and co-ordinated”. “ The level of care my wife receives is very good”. Seven Hills Nursing Home DS0000021811.V355721.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use 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 were able to make some choices about daily living and being involved in some social activities. People were able to maintain contact with family and friends ensuring that they continued to be involved in community life. Meals served at the home were of a good quality and offered choice. EVIDENCE: People were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home was made to feel comfortable whilst visiting their loved one. The home employed an activities worker from Monday to Friday. Unfortunately this person had recently resigned. The manager said they had advertised for a replacement and hoped that someone would be employed quickly. In the interim staff at the home had been allocated extra hours to ensure that activities were still available. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 15 The activities plan included reminiscence, games, light exercise and hair and beauty. On the day of the site visit, there was no planned activity, however staff were seen spending time with people on a one to one basis. Due to people’s disabilities, this was time well spent and people benefited from this individual time and attention. Relatives said: “People rarely get taken out for a change of environment. The staff say its too expensive and they’re short staffed”. “I would like there to be more activities that are suitable for people with mental health problems” “I think people would enjoy playing musical instruments, because they seem to enjoy music so much”. “I sometimes think there ought to be more activities, however people love conversation and they get plenty of that”. The manager and provider said that cost had never been an issue, when organising activities and trips and staff were always made available. Due to the severity of dementia that many people at the home suffered, it was difficult to take people out, although there was evidence of some trips out. The manager and provider said that they were open to suggestions about how they could improve the activities programme and said they would talk about this to relatives at the next relatives meeting. Menus were rotated on a four weekly basis. Choices were always available. The head cook had implemented a well balanced diet, however the menus were not always adhered to. This was understandable over the Christmas period but further checks confirmed that there were many days when alternatives were used. This could have accounted for the feeling from one relative that: “A lot of sausage and mincemeat is used. For dessert it’s usually mousse or rice pudding”. The manager and provider arranged for a meeting with the head cook and the homes cooks to address these concerns. One person spoken to said that he/she enjoyed the meals provided. Relatives said: Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 16 “The food is good, lots of fresh vegetables are offered”. “The food always looks like good home cooking”. The inspector made some observations during breakfast and lunch. Dependency levels at the home were high and many people needed help to eat. In the main staff were seen assisting people in a caring and supportive way. One member of staff was standing up as they assisted to feed. When this was discussed with them the staff member said it was because of the lack of space between chairs. At feedback the manager and provider said they would look at the space and reorganise so that staff could sit with people to assist with feeding. Meals were not rushed. Meals were not served to people until there was someone available to support them. Many people were eating soft or liquidised diets due to swallowing difficulties. People were appropriately sat either at the table or in an adjustable chair in an upright position. On the day of the site visit the dining room tables looked bare, with no placemats, cloths, crockery or condiments. The provider said that new placemats and crockery had been purchased but they had not started to use these, as they wanted to wait until the room had been decorated and the new furniture was in place. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18. People who use 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. Complaints procedures were in place and staff were aware of these. People and their relatives felt confident that any concerns they voiced will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. People said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. The home also recorded any informal concerns that were raised with them. These had been recorded in the complaints book and action had been taken to resolve any issues. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 18 Since the last inspection we had received one complaint. This was referred to the provider, was investigated and resolved. The complaint was not in direct relation to the care, staffing, facilities or service provided at the home. Staff spoken to were clear how to respond and record any complaints received. One relative said: “I have a very good overview as I visit daily and I have nothing to complain about”. An adult protection procedure was in place. Staff undertook training on adult protection to equip them with the skills needed to respond appropriately to any allegations. People spoken to said that they felt safe living at the home. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 19 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): Standards 19, 24 and 26. People who use 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 home was well maintained, clean and fresh smelling. Homely touches had been provided to create a comfortable environment. Controls of infection procedures were in place, which promoted people’s health and welfare. EVIDENCE: The home was clean and tidy. Staff should be commended for the extremely fresh smelling environment. A rolling programme of refurbishment and redecoration was underway. Many communal areas and bedrooms had been decorated and had new furniture. Carpets had also been replaced. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 20 A maintence person was employed to help look after the environment. Homely touches were provided, which enhanced the feeling of warmth and wellbeing. Bedrooms seen were cosy. Some people spent a lot of time in their rooms, their beds were comfortable. Bed linen and towels had been replaced. The provider had a programme of refurbishment and redecoration that ensured that the home was aesthetically pleasing and free from hazards. Work being undertaken was adding to the comfort and well being of the people living in, working and visiting the home. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. Laundry facilities were sited so that soiled clothing was not carried through food preparation or food storage areas. There was a sluicing disinfector and hand washing facilities in areas where infected material and clinical waste were handled. The manager said that staff were being enrolled onto an in-depth training course about infection control, which would enhance their understanding and skill within this area. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff were provided to meet the needs of people. The recruitment information obtained for some staff was insufficient to adequately protect the welfare of people who lived at the home. Staff had completed training, including induction. Further essential training had been planned. EVIDENCE: Staff rotas showed that there was sufficient staff employed to meet the needs of people. Staff said that there were usually enough staff, except sometimes at holiday times and if there was staff sickness. Regular bank staff and staff working extra hours were used to cover at these times. Staff said this helped to ensure that people’s needs were met in a consistent way. Staff said they worked well together as a team and enjoyed working at the home. Staff were able to talk about the various training courses that they had attended, for example, Moving and Handling, Food Hygiene, Adult Protection Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 22 and Fire. Some staff had not received updated training in moving and handling and adult protection. Following the inspection the provider forwarded information to confirm that staff had been booked onto this training at the first available date. Some other specialised topics, for example, dementia care had been delivered by the Sheffield Partnerships for Older Peoples Projects (POPP’s) team. There are a high number of people who require a soft, thickened or liquid diet. The inspector believes that people would benefit if staff undertook training in feeding people with eating and swallowing difficulties. One health professional said: “Staff would benefit from training in the care of people with behavioural problems”. The manager and provider said they would arrange any training that would benefit people and enhance staff skills. Eleven care staff had achieved NVQ Level 2 or above in care. A number of care staff had also commenced the training. This clearly met the required minimum of 50 of the staff team trained to NVQ Level 2 in Care. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Three staff files checked identified that the member of staff had received induction training when they commenced work. Four staff records of employment were checked. Two staff had been recently recruited at the home and the other two had not commenced work but had been given start dates. There were shortfalls in the information that should have been gathered during the recruitment process. • • • • • • The Criminal Records Bureau (CRB) check on file for three people were not up to date and had not been obtained by the home. No Protection of Vulnerable Adults (POVA) first checks had been carried out. One application form was not completed. One person only had one reference One reference was not fully completed or signed by the referee Gaps in one person employment record had not been checked out. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 23 Following the site visit the provider promptly confirmed in writing that POVA first checks had been completed for the two staff members working in the home. He also confirmed that the two new staff members would not commence work until CRB checks had been obtained and other gaps in their recruitment records had been completed. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 24 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): Standards 31, 33, 35, 36, 37 and 38. People who use 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 manager’s leadership approach benefited people and staff. Quality assurance systems meant that the home was run in the best interests of everyone. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. In the main people’s health and safety had been promoted and protected. EVIDENCE: The manager is a nurse who is competent and experienced. She was clearly committed to ensuring that people living in the home were consistently well cared for, safe and happy. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 25 Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. One relative said: “The manager does a great job, she sets the tone of kindness and respect”. The manager and provider had many ways in which to check out the quality of the service that they were providing. Regular staff and relative meetings were arranged. The home carried out twice-yearly satisfaction surveys, copies of these were seen and comments had been acted upon. The inspector spoke to the provider and manager about publishing a report with the results of the surveys. These could then be made available to prospective users and their representatives. The home handles money on behalf of some people. This was checked for three people. Account sheets were kept, receipts were seen for all transactions and monies kept balanced with what was recorded on the account sheet. Formal staff supervision, to develop, inform and support staff took place at regular intervals and staff said that they found this useful and beneficial. Equipment at the home was serviced and maintained. The maintence person said that he checked the fire system each week. However this was only recorded if the fire system check was also used as a fire practice. The inspector spoke to the maintenance person about the need to record that the fire system had been checked each week. Staff said that they had received fire training. Staff had recently been involved in a number of fire drills and practices. The company employed a person who was responsible for completing the fire risk assessment. The provider confirmed this was completed and there were no outstanding areas of concern. During the site visit a medication cream and lotion had been left in a toilet. The manager was asked to remove these immediately. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 26 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 2 Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13 Requirement To ensure people’s health and welfare: MAR sheets must be fully completed and signed at the time of medication administration. Codes on MAR sheets must be used consistently. 2. OP29 Regulation 19, Schedule 2(7) Regulation 19 Schedule 2 19 The staff member without a CRB must not undertake care tasks without supervision until their CRB checks and POVA first check has been gained. Staff must not be recruited prior to an appropriate CRB disclosure being received. There must be a thorough recruitment procedure, based on ensuring the protection of people. As per the homes policy and procedure, fire system checks must be carried out weekly. These checks must be recorded DS0000021811.V355721.R01.S.doc Timescale for action 08/01/08 08/01/08 3. OP29 08/01/08 4. OP29 08/01/08 5. OP38 23 (4) (c) (v) 08/01/08 Seven Hills Nursing Home Version 5.2 Page 28 in writing. 6. OP38 13 Substances that could be hazardous to health must be kept locked away at all times. 08/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP15 OP30 OP33 Good Practice Recommendations So that people receive a wholesome, appealing and balanced diet, the well thought out menus should be adhered to. Staff should be provided with training in caring for people with behavioural problems and assisting to feed people with eating and swallowing difficulties. The quality assurance system should be further developed. The views of people, relatives and professionals are sought and the results of these consultations should be published. Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Seven Hills Nursing Home DS0000021811.V355721.R01.S.doc Version 5.2 Page 30 - 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. 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