Inspection on 21/09/05 for Acocks Green Nursing Home

This inspection was carried out on 21st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Acocks Green Nursing Home 05/06/07

Acocks Green Nursing Home 22/06/06

Acocks Green Nursing Home 29/11/05

Acocks Green Nursing Home 09/03/05

Acocks Green Nursing Home 26/11/04

Acocks Green Nursing Home 16/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Acocks Green Nursing Home 1079-1081 Warwick Road Acocks Green Birmingham B27 6QT Lead Inspector Amanda Lyndon Announced 21 September 2005 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 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. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Acocks Green Nursing Home Address 1079-1081 Warwick Road Acocks Green Birmingham B27 6QT 0121 707 2611 0121 707 6549 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Care Management Ltd Mrs Petra Thompson Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56) of places Physical disability over 65 years of age (56) Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Both male and female older people with nursing care needs over 60 years of age. Date of last inspection 09 March 2005 Brief Description of the Service: Acocks Green Nursing Home provides 24 hour nursing care for older adults aged 55 and over. It is a purpose built home and is situated in a residential area of Birmingham, close to a local shopping centre with all amenities including public transport. The home has two floors and accommodation consists of single rooms with some en-suite facilities. There are two double rooms available and communal space consists of two large lounges on the first floor and one large and one smaller lounge on the ground floor. There is an attractive garden situated to the side and rear of the Home with a patio area and garden furniture for residents to access weather permitting, and car parking is available at the front of the home. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was undertaken by two Inspectors when there were fifty four residents living in the Home and information was gathered from speaking with the residents, visitors and staff, observing the care staff perform their duties and examining care, medication and health and safety records. A tour of the premises was undertaken. Prior to this inspection the Commission and Social Care and Health had received a number of complaints raising issues regarding aspects of residents’ health, safety and care delivery and part of this inspection was to assess any progress made following these concerns. A number of the elements of complaints received were upheld, however it was pleasing to note that the Management team had addressed the majority of these issues and were closely monitoring the service provided. The Commission did not receive any completed comment cards in respect of the service provided, however the majority of resident and visitors met during the inspection expressed their satisfaction about the service provided. What the service does well: Residents are generally well supported by the staff to meet their health, welfare and personal care needs and their personal preferences are taken into account in respect of this. One resident said “ The staff are very good and answer the call bell promptly if I need help”. Another resident said “ The staff are very good at helping me to have a bath”. There is a wide range of activities on offer for residents to participate in should they choose, including both group and individual activities and written documentation in respect of this is good. Residents receive a choice of wholesome and well balanced meals, which meet any dietary needs and can choose where they are served their meals. One resident said “ I enjoy having my meals in the dining room and talking to the other residents”. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 6 Bedrooms contain many personal items to reflect residents’ individual tastes and preferences to ensure that they feel comfortable in their surroundings. One resident said “ I really love my room, it is very comfortable”. The Home has large, well maintained gardens, including a seaside themed area and these were easily accessible to residents for their enjoyment. One resident said “ I really enjoy sitting in the garden”. The Home provides a homely, comfortable, safe and generally clean environment for residents to live in. One resident said “ The cleaners are very good and clean my room every day”. Residents are invited to regular group meetings to discuss the service provided External Managers visit the Home regularly to monitor the service provided. What has improved since the last inspection? A number of requirements made at the previous inspection had been addressed. Medication is now administered in a safe manner. Residents are now supported to wear clothing appropriate for the time of year. All bedrooms have now been fitted with an appropriate privacy lock which can be overridden in the event of an emergency and this ensures that residents’ privacy is respected. The revised robust staff recruitment practice ensures that residents are now protected. Relatives are invited to group meetings to discuss the service provided. Training and supervision is now provided for the staff team to ensure that they have the appropriate knowledge and support to work competently within their job roles. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 7 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. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 The assessment and admission processes are generally comprehensive, however, contracts detailing terms and conditions are not available for all residents. Care reviews are being undertaken to ensure that the Home can meet the needs of the current residents. EVIDENCE: The Organisation had produced a comprehensive statement of purpose and service user guide and these contained all relevant information. The service user guide was also available in an audio cassette format. Comprehensive contracts of terms and conditions of residency were issued to privately funded residents, however these were not issued to residents who were funded by other means. Senior staff undertake assessments of all prospective residents’ care needs prior to admission and prospective residents are invited to spend the day at the Home and have a meal with other residents. Acceptance letters are not Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 10 issued to new residents, however all residents are admitted for a trial period of four weeks. A high proportion of residents had dementia care needs and Acocks Green Nursing Home does not have a category of registration for this. These people had been living at the Home for a long period of time and mental health risk assessments had not been undertaken. The Registered Manager had recently commenced residents’ care reviews. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, & 10 Residents’ health and personal care needs are generally well met, however some care practices and documentation in respect of this was inadequate, failing to ensure that residents’ needs will be met. Medication is administered in a safe manner. Residents are generally supported in a respectful manner by residents, ensuring that their privacy and dignity are maintained. EVIDENCE: Comprehensive physical and social assessments of residents needs are undertaken on admission to the Home, including some of the preferences in respect of the routines of residents and care plans are derived from these. Some of the care plans identified the specific information in respect of how the staff must support the residents in these areas, however other care plans were not written in good detail. Care plans evaluated were agreed and reviewed with the involvement of the resident and/or their relative. Daily records in respect of personal care afforded were not always completed, however daily reports in respect of health care needs were recorded in good detail and residents were weighed at least each monthly. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 12 Although the information was available within the evaluations and wound assessments were ongoing, wound care plans did not always identify the wound dressing of choice and the wound care regime as identified within the care plan was not always followed. Residents’ risk assessments had been completed including the risk of pressure sore development, falls, nutrition and moving and handling, however these were not always written in detail. Bed safety rail risk assessments did not include detail of the risks involved in the use of these and consent was not always obtained from the resident and/or their representative regarding the use of these. Not all of the standard care planning documentation was relevant for all residents and it is recommended that information that is not applicable for every resident be removed from individual care plans for ease of auditing. Residents have the option of retaining their own General Practitioner on admission to the Home (if the GP is in agreement) and have access to other Social and Health Care professionals including Social Workers, Dieticians, Opticians and Tissue Viability Nurses. One element of a complaint received was in respect of poor communication between staff members and this has resulted in poor emergency care being afforded to residents. Plans and systems were now in place to rectify this. Another complaint received was regarding the inadequate supervision of residents whilst in lounges. As a result of this staff allocation records had been introduced and these identified the daily responsibilities of each staff member throughout the working shift. On the day of inspection there was a very short period of time when the residents in the first floor lounge were not supervised. One resident said “ The staff are very good and answer the call bell promptly if I need help”. The Commission received a complaint regarding the inadequate support from staff being afforded to residents in respect of meeting their personal care needs. On the day of the inspection the residents appeared to be well supported to meet their hygiene needs, hair styles were neat, and their clothing was appropriate for the time of year. One resident said “ The staff are very good at helping me to have a bath”. There had been improvements in respect of the safe management of medication since the last inspection and this included Controlled Drugs. Reasons for non administration of medication were recorded, medication audits were undertaken each month and residents’ medication reviews had been undertaken recently. The arrangements for the receiving, administration and disposal of medicines was good. The medication fridge temperatures were not Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 13 recorded daily, one vial of eye drops were out of date and other vials of eye drops had not been dated when opened. All bedrooms had now been fitted with appropriate privacy locks and these could be overridden in the event of an emergency, however none of the current residents had expressed a wish to hold their key, the reasons for this must be recorded within their care plans. In addition, each bedroom contained a lockable storage facility. Residents have the option of a private telephone line in their bedrooms and plans are in place for a pay phone to be installed. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 The activities on offer generally meet the needs and expectations of residents living at the Home and residents are able to maintain contact with their families and friends with support from the staff. Residents are able to exercise some choice over their daily lives and the activities that they choose to participate in which promotes their independence and individuality. Residents receive a wholesome and appetising diet which meets any special dietary needs. EVIDENCE: The Home employs a part time activities organiser and there was a range of activities for the residents to participate in should they choose, including Progressive Mobility, visiting library, reminiscence and entertainers . Residents’ birthdays are celebrated, the hair dresser visits twice a week and Holy Communion was available. Written documentation was available in respect of the residents who participated in each activity and any action taken following specific requests made by residents in respect of how their social needs will be met. Trips outside of the Home had not been arranged recently as the tax disc had been stolen from the minibus. A children’s programme was on the television in one of the communal lounges and this is not considered to be appropriate viewing and was not the choice of residents. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 15 The first issue of a newsletter had been produced recently and this included detail of planned activities and fund raising events and the availability of Registered Manager to meet with residents and relatives. There was an open visiting policy, comments were received prior to the inspection that communication between relatives and the staff was poor at times, however measures had been implemented to improve this. The main meals of the day were wholesome and nutritionally balanced and there was a choice of at least two meal options. Menus were accessible to residents, however these did not identify the supper time snack meal options on offer. Special diets are catered for including pureed, diabetic, low fat and soya diets and some of the food is home cooked using high energy ingredients. The meals were well presented and the portions of the pureed diet were served separately in keeping with good practice. One resident said “ I enjoy having my meals in the dining room and talking to the other residents”. A daily record of food provided for each resident was not kept. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The complaints procedure is comprehensive and is accessible to residents and their visitors. Overall, the Home now has good systems in place to protect residents from abuse. EVIDENCE: The Organisation has produced a comprehensive complaints procedure and this was on display in the Home and within the service user guide and statement of purpose. Since the previous inspection CSCI had received a number complaints about the service provided at Acocks Green Care Centre and these were regarding aspects of residents’ health and safety, poor staff attitudes and communication and poor care delivery. A number of the elements of the complaints received were upheld. Part of this inspection was devoted to assessing any progress made following these concerns and it was pleasing that the Management team had been proactive and had addressed the majority of these issues and were closely monitoring the service provided at the Home. There had been an incident involving a resident exhibiting physically abusive behaviour towards another resident. The appropriate authorities had not been informed about this. The adult protection policy included detail about indicators of abuse and incorporated Birmingham Multi Agency guidelines, however it did not provide the contact details of any relevant local authorities to be notified. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 24, 25 & 26 Residents are provided with a homely, comfortable and generally clean environment to live in. Aids and adaptations available do not meet the needs of all residents. EVIDENCE: Acocks Green Care Centre had large, well maintained gardens, including a seaside themed area and these were easily accessible to residents for their enjoyment. One resident said “ I really enjoy sitting in the garden”. The internal environment of the Home was comfortable and homely in style and there was a rolling programme of redecoration and replacement of furniture in progress. New dining tables and chairs and lounge arm chairs had been purchased since the previous inspection and furniture and floor fittings were of a generally good standard. There were four lounges and two dining rooms and these were attractive and decorated to a high standard. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 18 There were four assisted bathing and two shower facilities, meeting the needs of the current residents. Appropriate pressure area relieving equipment was available as required, however the majority of beds were not of a nursing care type. Risk assessments must be undertaken in respect of the needs for appropriate nursing adjustable beds for those residents deemed to be in need. Residents’ bedrooms contained many personal items that reflected residents’ individual tastes and a nurse call facility. One resident said “ I really love my room, it is very comfortable”. The internal temperature within the Home was comfortable, window restrictors had been fitted and radiators were of a low surface type. The Home was found to be clean and fresh on the day of the inspection with the exception of one bathroom floor and this was found to be soiled with faeces and one bedroom in which there was a strong smell of stale urine. One resident said “ The cleaners are very good and clean my room every day”. There was an effective and hygienic system for the laundering of residents’ bed linen and personal clothing items. Appropriate contracts were in place for pest control and disposal of clinical waste and there were appropriate and hygienic facilities for the cleansing of commode pots. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Adequate staffing levels are maintained to meet the needs of residents. The robust recruitment practice ensures that residents are protected and staff now undertake relevant training to ensure that they are competent to do their jobs. EVIDENCE: The staffing rotas identified that the Home was working within approved staffing levels and agency staff is used to cover periods of staff sickness and annual leave. In addition to this plans were in place for an additional registered nurse to be on duty during the week day mornings. Domestic, laundry, kitchen and maintenance staff provide ancillary support to the care staff and an administrator had recently been appointed. The Management team provide on call support to the person in charge of the shift Staffing rotas identified that a number of staff worked an excessive number of hours each week and one staff member worked a combination of day and night shifts without adequate rest periods between shifts. One visitor said “ I visit very often and the Home is more settled now, I find the staff to be very nice and you know which staff will be on duty whenever you visit”. Another visitor said “ I get on very well with all of the staff and I can ask them for anything”. The Commission had received a number of complaints regarding staff conflicts and poor relationships between staff members and the Organisation must Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 20 address this to ensure that this does not have a negative impact on the care afforded to residents. Staff personnel files examined contained all information as required by Regulations. Pre employment health declarations are undertaken and staff were deemed safe to work with vulnerable people. A statement of terms and conditions of employment and a job description are issued to staff. New staff undertake an induction on commencing employment at the Home and this includes health and safety issues. Staff had undertaken training relevant to their job roles including dementia care, protection of vulnerable adults, care planning and challenging behaviour. A staff training needs analysis had been undertaken and this included individual staff training records. It is recommended that staff training records include the content and duration of each training session, together with an indication of when updated training will be necessary Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 & 38 The planned extra managerial support should provide a well managed Home that is run for the benefit of residents. There are systems in place to monitor the quality of the service on offer and the systems for resident consultation are good. Residents’ financial matters are safe guarded through robust accounting of personal allowances. The recent staff training undertaken should ensure that residents are supported and protected by competent staff. Maintenance checks of equipment used ensure that the safety of residents is protected. EVIDENCE: The Registered Manager is a Registered General Nurse and has had much experience in caring for older people and has a Diploma in Management Studies and Masters Degree in Business Administration. In addition, there is a Care Manager commencing employment at the Home in the very near future. The Registered Manager had introduced an “open door” policy at certain times in order for residents and their visitors to discuss any issues with her. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 22 External Managers had held separate relatives and staff meetings recently to discuss the service provided at the Home and to reinforce the importance of staff following Organisational policies and procedures and maintaining good working practices. Regular residents’ meetings are held in the Home. Service satisfaction questionnaires had been distributed to residents and a report had been produced based on the findings of these. The report had been distributed to each resident for their information. In addition to this, quality monitoring visits are undertaken regularly by external Managers. The staff do not manage the finances of residents, with the exception of the safe keeping of their personal allowances as requested. The system for the management of this was good, separate transaction records were maintained and receipts of all personal items purchased out of residents’ money were available. Plans were in place for formal staff supervision and appraisal to be arranged, however this was yet to be fully implemented. Health and safety checks of equipment used including portable electrical appliances, fire alarm system, gas appliances and hoisting equipment were undertaken as required, however the outcome of the latest electrical installation service was found to be unsatisfactory and there was no evidence available to confirm that any remedial action had been undertaken. Comprehensive fire risk assessments had been undertaken recently. Risk assessments had been undertaken in respect of the premises and staff welfare, however these had not been reviewed for a long period of time. Bedroom doors had now been fitted with fire guard closures. There were no requirements outstanding following the last Environmental Health inspection. Following the recent concerns about poor care practices, staff had undertaken training about health and safety issues including moving and handling, fire safety, health and safety and basic food hygiene, accident and incident reporting and safe use of bed rails. A number of staff had a first aid certificate and a fire drill had been undertaken recently. The Organisation had produced a comprehensive procedure in respect of staffs’ responsibilities in the reporting of accidents, however despite this, staff had not followed the correct procedure for accident reporting on a number of occasions. It was pleasing that measures had been introduced to rectify this. There had been a number of serious accidents involving residents as a result of staff failing to follow correct moving and handling procedures. On the day of Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 23 the inspection a wheelchair was in use without the foot rests and this poses a risk to the safety of the resident. This was brought to the attention of the Management team and was addressed without delay. In addition to this, moving and handling risk assessments of all residents had been updated. The accident book identified a number of accidents and unexplained bruising involving residents and the Commission had not been notified of these. In addition to this, written evidence was not available to demonstrate that any follow up action and monitoring had been undertaken to minimise the risks of similar accidents occurring again and the outcome of injuries sustained following accidents were not documented. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 3 3 3 2 x 3 3 2 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x 3 2 x 2 Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 25 yes Are there any outstanding requirements from the last inspection? 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. 2. Standard OP2 OP4 Regulation 5(b) 14(1)(d) Requirement Contracts of terms and conditions of residency must be issued to all residents. The Registered Manager must confirm in writing to all new residents that the Home can meet their care needs. Mental health risk assessments must be undertaken as deemed necessary for current residents. (timescale of 09/05/05 not met) The appropriate authorities must be informed of the changing care needs of current residents when the Home cannot meet these needs. Moving and handling risk assessments must include detail of the action to be taken should a resident fall. (timescale of 09/04/05 not met) The care planning system must be further developed to include: The actual care to be afforded to residents (including wound care) Detail of how residents social care needs will be met. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 26 Timescale for action 30/12/05 30/11/05 3. OP4 12(1) 15/12/05 4. OP4 37 30/11/05 5. OP7 13(5) 15/12/05 6. OP7 15 15/12/05 Residents risk assessments must be written in more detail. Bed safety rail risk assessments must include detail of the risks involved in the use of these and consent must be obtained from the resident and/or their representative prior to the use of these. Wound care afforded must reflect the wound care regime as identified in the care plan. All cupboards storing medication must be lockable. This requirement was not assessed on this occasion. Medication fridge temperatures must be recorded daily. Eye drops must be dated on opening and discarded 28 days after that date. The reason that a resident does not hold the key to their bedroom must be recorded within their care plan. Residents must be consulted regarding the choice of televison programmes on show in communal areas of the Home. A daily record of food provided must be kept for each resident in order to determine the nutritional content of their diet. The adult protection policy must include the contact details of the relevant local authorities. Risk assessments must be undertaken in respect of the needs for appropriate nursing adjustable beds for those residents deemed to be in need. Bathrooms must be kept hygienically clean and ready for the next persons use. 7. 8. OP8 OP9 12(1) 13(2) 30/11/05 30/11/05 9. 10. 11. OP9 OP9 OP10 13(2) 13(2) 12(4)(a) 30/11/05 30/11/05 31/12/05 12. OP14 12(3) 15/11/05 13. OP15 17(2) 15/12/05 14. 15. OP18 OP19 13(6) 12(1) 23(2)(n) 15/12/05 15/12/05 16. OP26 13(3) 23(2)(d) 21/09/05 Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 27 17. 18. OP26 OP27 23(2)(d) 18(1) The Registered Manager received this in the form of an immediate requirement. Action must be taken to ensure 30/11/05 that the stale smell is eliminated in respect of one bedroom. Staff must not work an excessive 21/09/05 number of hours each week and must not work a combination of day and night shifts without adequate rest periods in between. The Registered Manager received this in the form of an immediate requirement. The Registered Manager must 21/12/05 ensure that the programme for formal staff supervision and appraisal is fully implemented. Risk assessments in respect of 15/12/05 the premises and staff welfare must be reviewed and updated. The Commission must be 21/09/05 informed of all deaths, illnesses and other events, including unexplained bruising that may affect the health or welfare of residents. The Registered Manager received this in the form of an immediate requirement. Wheelchair foot rests must be 21/09/05 used at all times. The Registered Manager received this in the form of an immediate requirement. Accident records must include 30/11/05 information about any injuries sustained and any follow up action taken following an accident involving residents to minimise the risks of a reoccurrence. 19. OP36 18(2) 20. 21. OP38 OP38 13(4) 37 22. OP38 13(4)(5) 23. OP38 13(4) Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 28 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. 4. 5. Refer to Standard OP7 OP7 OP15 OP27 OP30 Good Practice Recommendations Personal care records available should be completed each day by the care support staff. It is recommended that information that is not applicable for every resident be removed from individual care plans for ease of auditing. Menus should identify the snack time meal options on offer The Organisation should address any staff conflicts to ensure that this does not have a negative impact on the care afforded to residents. It is recommended that staff training records include the content and duration of each training session, together with an indication of when updated training will be necessary. Acocks Green Nursing Home E54 S24814 Acocks Green NH V244031 210905 Stage 2.doc Version 1.40 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 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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