Inspection on 10/07/08 for Acorn Hill Nursing Home

This inspection was carried out on 10th July 2008.

CSCI found this care home to be providing an Adequate 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

Acorn Hill Nursing Home 10/06/09

Acorn Hill Nursing Home 21/09/07

Acorn Hill Nursing Home 12/04/07

Acorn Hill Nursing Home 12/04/06

Acorn Hill Nursing Home 02/09/05

Acorn Hill Nursing Home 15/04/05

Acorn Hill Nursing Home 02/09/04

Acorn Hill Nursing Home 28/01/04

Similar services:

Trevayler Residential Care Home

St Marys Nursing Home

Thornham Grove

Cheaney Court Care Home

Thistle Hill Hall

Chater Lodge

Conifer Lodge

Tixover Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Crown Hills Nursing Home Radstone Walk Rowlatts Hill Leicester LE5 4UH Lead Inspector Keith Charlton Unannounced Inspection 10th July 2008 09:20 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 Crown Hills Nursing Home DS0000001897.V368203.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. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Crown Hills Nursing Home Address Radstone Walk Rowlatts Hill Leicester LE5 4UH 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) 0116 2760600 0116 2761428 saidz@btinternet.com GB Care Ltd Manager post vacant Care Home 49 Category(ies) of Dementia (49), Mental disorder, excluding registration, with number learning disability or dementia (49), Physical of places disability (49) Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC To residents of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Mental Disorder, excluding learning disability or dementia - Code MD Physical Disability - Code PD 2. The maximum number of residents who can be accommodated is 49 Date of last inspection 21st September 2007 Brief Description of the Service: Crown Hills Nursing and Residential Home is a care home offering accommodation for up to forty-nine older people. The home is registered to admit older people with dementia and/or mental disorders and physically disabilities. The home is located in a residential area to the east of Leicester. It is easily accessed by road using the outer ring road. The centre of Leicester is approximately fifteen minutes away by car and there are adequate car parking spaces. A bus service is available from outside the home with more frequent bus services available near to the home. The building itself is a purpose built property offering accommodation on three levels. The home is equipped with a slow moving lift. There is a large garden to the rear of the property with a lawned area, established plants and trees and a patio area with seating. All areas of the home and outside areas are accessible for people with mobility difficulties. Fees range from £425 per week to £551 per week – this information was provided by the Acting Manager on the day of the inspection. Crown Hills Nursing Home DS0000001897.V368203.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 1 star. This means the people who use this service experience adequate quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them, visitors and care staff and observation of care practices. This was an unannounced Inspection. The Acting Manager was present and helped in carrying out the inspection. At the time of the inspection the Acting Manager had only been in post for approximately a month so was still assessing the home and the improvements that were needed as described in the Annual Quality Assurance Assessment. Planning for the Inspection included looking at the Annual Quality Assurance Assessment completed by the Acting Manager, which describes how services are provided by the home, notifications of significant events sent to the Commission for Social Care Inspection and the issues contained in the previous Inspection Report. There have not been any complaints made to the Commission for Social Care Inspection about the service since the last full inspection. There have been two Safeguarding of residents issues regarding accidents to a resident and a resident’s behaviour towards another resident, and there are systems in place to deal with any such reoccurrence of such issues. The Inspection took place between 9.20 and 17.10 and included a selected tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with five residents, four members of staff, two visitors and the Acting Manager. The inspector also took an expert by experience, someone who has experience of care services, to talk to residents and see whether they were satisfied with the home. His remarks have been incorporated into this Inspection Report. What the service does well: Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 6 There was again evidence of promoting the welfare of residents in terms of good relationships between staff and residents with staff listening and consulting with residents. Residents said that the care provided by staff was very friendly and respectful. Two choices are offered for lunch every day, as per the National Minimum Standard, so that meal choice is seen to be available to residents. Facilities used by residents are odour free, and the refurbishment programme is ensuring that they will be more comfortable and homely for residents. Staff are encouraged to have training to equip them to meet residents needs and have supervision to support them in their jobs. Residents, staff and visitors thought that the Acting Manager was doing a very good job in that she was friendly, efficient and ready to listen to anyone who needed help. The Acting Manager was very enthusiastic about providing a high quality service for residents and open to discuss any area of practice and quickly responded to the inspection by providing information to bring in new systems to improve the care of residents. Residents comments included: ‘We are happy with the staff. They do a good job’ ‘The manager is always available and she listens to what you say.’ What has improved since the last inspection? What they could do better: Residents welfare could be more effectively met by ensuring that: All aspects of care – e.g. dates of previous medical checks are in Care Plans to assist staff to meet all residents needs and that Care Plans are detailed enough to provide individual care. Staff need to ensure that residents health needs are Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 7 covered at all times, as per calling on Medical Services when necessary and reading all residents Care Plans so that they are aware of all residents care needs. The home need to review the signing of the home to assist residents with dementia – e.g. larger sign notices, same colour doors for bathrooms, memory boxes with treasured items for individual residents to provide prompts and stimulation to make everyday living clearer for them, particularly for residents with dementia. The Complaints Procedure needs to be clearer for residents and their representatives so that any complaints are fully dealt with. The staff training programme is generally comprehensive though would aid staff understanding if training on all residents conditions – parkinsons disease, diabetes, strokes etc – were added to the programme. 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. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed before admission so that staff are able to meet their needs. EVIDENCE: Residents said that they had the offer of someone from the home coming to see them before admission to discuss their needs and they were encouraged to visit. ‘’ I could have visited to look around to meet the staff and other residents and see what the room was like’’. This reflects what was said in the Annual Quality Assurance Assessment. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 10 A visitor said she had not received a contract. The Acting Manager said this would be supplied shortly. An assessment was inspected and it contained lots of detail of relevant information as to residents needs, as per the National Minimum Standard, which helps to ensure that all the care needs of residents is covered from day one of their admission. The Manager said in the Annual Quality Assurance Assessment that assessments are carried out for all prospective residents as per the policy contained in information about the service and that a service users guide is provided to residents/ relatives to describe the home’s services. Assessments were seen on file – this allows staff to be aware of a new resident’s needs. The assessments are to have details of previous medical check ups on them so as to alert the staff to encourage regular checks to meet residents care needs. The service does not offer intermediate care. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of residents living in the home are not always well met. EVIDENCE: Residents said that the care they received was good: ‘’When they help me they are careful and do not rush me’’. Residents spoken with said that they could not recall having Care Plans, and need to be reminded they can see their Care Plans and discuss them if they wished to ensure that their needs are accurately recorded. ‘’I have never heard of a Care Plan. If I wanted I am sure they would give it to me’’. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 12 Care Plans seen by the inspector contained a good amount of information information as to the physical, social and medical needs of residents though they were unwieldy – the Acting Manager said she would set up a summary so staff can quickly get information, which she swiftly sent to the inspector the day after the inspection. There was no detail regarding some aspects, e.g. dates of the last medical checks for the dentist, optician etc, toiletting programmes (full incontinence assessments are needed) and turning charts so no evidence that residents had their individual needs met. The Acting Manager said she would set up a summary so staff can quickly get information, which she swiftly sent to the inspector the next day. A visitor informed the expert by experience that she had found her relative wet through one day, that she had pointed this out to staff but he remained unchanged for over an hour. Clearly, if true, this is not acceptable care practice and something the Acting Manager needs to follow up. Risk assessments were found to be a part of the plans so that staff know how to keep residents safe. A resident was found to be in a recliner though there was no Risk Assessment on file or whether he had agreed to this equipment, as it could be seen as restraint. Monthly reviews of residents needs were noted in Care Plans and were kept up to date to ensure needs are fully up to date to ensure care is relevant. Staff said they had not read all the Care Plans. The Registered Manager said she would ensure that this is carried out. The Acting Manager said she would set up a sheet to track who had read Care Plans, which she swiftly sent to the inspector the next day. A resident said that the staff helped her to walk again, to which she was very grateful to them. Residents said when they felt ill then staff would swiftly summon medical assistance – residents contacts with medical personnel were documented in their Care Plans. Accident records were viewed which showed that medical services were not always properly referred to on occasions when there had been a serious injury, e.g. head injury. The Acting Manager said this issue would be followed up. The inspector observed that staff were friendly and respectful to residents and encouraged in a friendly manner at the residents pace. The ex by ex noted that staff did not notice when a resident with a cup of tea in his hand precariously balanced on the residents knee and was falling asleep so was at risk of being scalded by the tea. The Acting Manager said she would provide training to staff regarding observational skills. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 13 The Acting Manager confirmed that all staff that issue medication undertaken medication training and this was recorded on staff records though this is to be updated in the near future by the pharmacist. Medication record sheets were found to contain gaps so it could not be said with all confidence that residents had received all their medication, which could affect their health. The Acting Manager said this issue would be put in place. There was one query regarding controlled drugs and their return, which the Registered Manager said would be followed up. The policy of the home is that residents can handle their own medication if they are safe to do so and choose to do so. The residents spoken with appreciated the staff holding their tablets and giving them at prescribed times. Medication is kept securely in the medication trolleys and controlled medication kept more securely through being kept in a properly robust cabinet. Crown Hills Nursing Home DS0000001897.V368203.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): 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents living at the home do not have a sufficient opportunities for activities. Meals continue to be seen as good. EVIDENCE: Residents again said that there used to be a lot of activities but since the Activities Organiser left the range of activities on offer was reduced and there were a number of comments that there should be more activities. ‘’We get hardly any activities. It would be nice to do something every day’’. There was a displayed information on the noticeboard about a theatre group visiting which happened and that the ex by ex said residents enjoyed. ‘’We like trips out. There was a boat trip two years ago which I enjoyed but there are no outings now’’. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 15 ‘’We would like to do things like bingo, quizzes, crafts and old time singing.’’ The Acting Manager said in the Annual Quality Assurance Assessment that the home was looking to increase this area and on the day of the inspection said that she thought there was a need to employ another Activities Organiser to work on a daily basis. It is also recommended that a staff member receive specific training so as to be able to plan to provide relevant activities for residents with dementia. Some residents said they liked the garden and one resident told the ex by ex that she would like staff to help her walk in the garden. The Acting Manager said this issue would be put in place. Staff and residents said residents can go out if they wish and are able to. One resident said she went out with her friend to have her hair done every fortnight. Residents said that prayers and regular church services and communion is held in the home and that they can go out to church if they choose. Residents said that their visitors were made welcome by staff and this was supported by the visitors comments. Residents said there were no rules in general though there was one comment that residents have to get up and go to bed before certain times for staff convenience. The Acting Manager is to follow this comment up to ensure residents have full choice in this matter. Residents said they were able to choose whether to stay in their rooms or go to the lounge etc., and staff respected this, and can keep alcohol in their rooms if they chose and there were no risks in them doing so. Staff said that it was important that residents were able to keep their independence so they could still do things for themselves. This was confirmed by comments made by residents. Most residents said that they thought the food was good. ‘’ I like the food. There is a choice’’. Though there was one comment that there is no choice in practice and staff give whatever there is to hand. The Acting Manager said she would follow up this remark. Residents preferences were recorded in their Care Plans and the cook said that he spoke to residents/ relatives regarding preferences when new people were admitted to ensure they got what they wanted. It is recommended that a cooked breakfast is added to the breakfast choice so that this is available to people. The Acting Manager said she had noticed this herself and its provision was already in hand. There was evidence that food choices for a resident from a minority culture was catered for on the Care Plan but this was not recorded. From comments Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 16 made, there needs to be more evidence that foods offered and supplied is based on the wishes of the resident. The Registered Manager said this would be followed up. Food records showed what variety of vegetables were offered and full food records are kept to evidence choice and variety. The food tasted was found to be of a good standard with a two course meal offered with two vegetables for one option followed by a a dessert. Crown Hills Nursing Home DS0000001897.V368203.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): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents views are listened to and acted upon. The Complaints Procedure needs to be altered to make it easier to make a complaint. EVIDENCE: Residents spoken with thought that if there was a problem then they were confident the management would sort it out: ’’ If I had a problem I am sure the manager would act on it quickly’’. ‘’I think everyone would be willing to help you get it sorted out’’. Complaints records are kept. There has been one complaint in the past year and there was detailed evidence of its investigation on file that had been followed up by management. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the lead Agency, the local Social Service Department, as per the National Minimum Standard. The new Commission for Social Care Inspection office address also needed to be added. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 18 The Acting Manager said these issues would be followed up. A staff member spoken to was not aware of the procedure regarding all Agencies to contact if the in house arrangement failed if abuse was witnessed or suspected. The Registered Manager said this issue would be put followed up by a short procedural statement being drawn up and displayed to help staff to follow the correct procedure and so be able to fully protect residents welfare if such a situation happens. There was evidence on the notice board that staff are shortly to receive Protection of Vulnerable Adults training. Crown Hills Nursing Home DS0000001897.V368203.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): 19,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents see facilities as homely, comfortable and odour free. EVIDENCE: Residents all said that they liked their bedrooms and they could bring in their own things. These were observed to be personalised and homely by the inspector, with personal items of residents furniture, pictures, photographs etc. ‘I was able to bring in things that I wanted’’. ‘’The home will look nice when they have finished doing it up’’. The home is being completely refurbished at the time if the inspection. This is due to be completed by September 2008 according to the Acting Manager. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 20 The garden area looked attractive and residents said they walked there and appreciated the fresh air if they chose. There is some signing to the environment to assist with residents with dementia, e.g. signs understandable to residents which may include photos on doors to make them more recognisable, though this may need extending – e.g. same colour doors for bathrooms, notice of time, day, weather in the lounge, large print for the displayed menu etc. It is recommended that this aspect is fully assessed and provided. Odour control was of a satisfactory standard with only a slight odour, which the Acting Manager said would be cleared when carpets had been replaced and she would look at what cleaning products were more effective in dealing with odour. Locks were of the sort that are unsafe in that staff could not get in if there was an emergency. The Acting Manager said this would be looked at and locks replaced as necessary. There was a comment made to the expert by experience that there is no telephone for residents use. The Acting Manager said there are three phones, which are cordless so can be used anywhere by residents. Crown Hills Nursing Home DS0000001897.V368203.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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet residents needs. Recruitment procedures in place to properly protect residents welfare but need to be improved. Staff training systems are in place to plan to equip staff to meet residents needs though more training on residents health conditions needs to be carried out. EVIDENCE: Generally residents thought there were enough staff though there was a comment that staff were very busy and it sometimes took time to help residents on occasion. This needs to be followed up by the Acting Manager. ‘’The staff are great. They will speak to you when they are not busy’’. ‘’If I ring they come quickly’’. There was one remark to the expert by experience that a relative queried an injury a few months previously, and a staff member responded curtly in front of other residents that the injury was accidental. The Acting Manager said this issue would be followed up. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 22 The staffing rota demonstrated that staffing that there are normally six care staff on duty with two Nursing staff during day time periods, then four waking staff at night. It was discussed with the Acting Manager that more domestic cover was needed in the afternoon/evening seven days a week and for two domestic staff to always be on at the weekend so that care staff are not being called upon to carry out domestic duties, so they can concentrate on residents needs. There is a cook seven days a week so residents nutritional needs are covered. Staff said there had been a lot training provided by the management of the home. Records seen by the inspector showed this and the notice board also had details of training in the near future. The Acting Manager said induction training for new staff would be with the recognised Skills for Care induction in the future. Specific training on residents conditions – e.g. stroke care, diabetes, parkinsons disease, hearing impairment etc, is still needed. The Acting Manager said she would add this to the training in house and that staff training for other issues, e.g. Infection Control is in hand. The Acting Manager said she had set up a Training Matrix to identify what training specific staff members need so this can be seen at a glance to make planning for this training needs easier to spot and organise. Staff said they were encouraged to undertake National Vocational Qualification level training. The Annual Quality Assurance Assessment stated that with staff completing the National Vocational Qualification level 2 then there will be over 80 of staff with this qualification, which easily exceeds the National Minimum Standard. Recruitment records were inspected with Criminal Records Bureau /Protection of Vulnerable Adults checks, identification in place to ensure that residents are fully protected from potentially unsuitable staff and have a proper check of competency etc. There was a query with only one reference on file for one staff member. The Acting Manager said this issue would be put in place. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 23 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): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management systems are not fully in place to protect the health and safety of residents. EVIDENCE: The Acting Manager has years of experience in providing care and management in residential care and is a Registered Nurse. Residents, staff and visitors spoken with said that the home was well run with management showing a commitment to residents and relatives. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 24 ‘’The new manager is very good. She always listens and does something about it’’. ‘’ Nothing is too much for the manager. She is friendly and gets things done’’. There was evidence on records that staff are supervised and supported. Staff also said this was the case. The Acting Manager said she is to organise regular residents/relatives meetings to ensure that there is a forum to air views and preferences, put forward suggestions etc so that residents feel they have an input into the running of the home. Staff Meetings have been regularly held and recorded so that care issues can be put to staff so that standards are high to benefit residents. The Acting Manager said she is to put a Quality Assurance system in place to review services on a yearly basis. These are recommended to meet the National Minimum Standard and give residents a further input into the running of the home. It is also recommended that they be also given to other interested parties - e.g. GPs, Social Workers, District Nurses etc. The results should also be included in the Statement of Purpose so that this information is available to residents and their representatives, with an Action Plan showing how the home has dealt with any issues that arise from the survey, so that residents quality of life is shown to be promoted. Residents monies records were found to be properly kept with running balances and two signatures had been usually recorded to show that transactions are witnessed with receipts available to prove that the home was keeping monies correctly. The Acting Manager could not locate Risk Assessments for safe working practices, which are needed to assess all health and safety issues in the home to see what measures need to be put in place to protect residents from any risks in the home. Fire Precautions: System testing was on the required monthly schedules for emergency lighting and weekly fire bell testing was also carried out, though had slipped in the previous two week – the Acting Manager said this issue would be put in place. Fire drills are carried out though there was a long gap between August 2007 and June 2008. They need to be done on a regular basis of at least every three months. There was also a fire risk assessment on file, though this appeared basic and needed review as there was no Risk Assessment regarding the current refurbishment and how this potentially affected fire safety. This needs to be carried out to ensure that proper fire safety systems are in place to protect residents. Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 25 A staff member was asked about the fire procedure but was not aware of the full procedure. The Acting Manager said this issue would be put in place. There was evidence on file that hot water temperatures are tested on a regular basis to ensure that residents are protected from scalding water. The Acting Manager is to look at this as the hot water temperature may be too low for residents wishing to have a hotter bath whilst keeping in line with the National Minimum Standard. Crown Hills Nursing Home DS0000001897.V368203.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 1 Crown Hills Nursing Home DS0000001897.V368203.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 OP8 Regulation 12 Requirement Residents health needs in respect of referring potentially serious injuries to Medical Services must be met at all times. Timescale for action 10/08/08 2. OP9 13 Recording of medication needs to 10/08/08 be full and evidence of all medication returned needs to be shown. An Activities Programme based on residents needs should be drawn up and supplied. The health and safety systems including fire safety systems in the home and Risk Assessments for safe working practices must be in place to protect residents from harm. 10/09/08 3. OP12 16 4. OP38 13 10/08/08 Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 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. Refer to Standard OP7 Good Practice Recommendations Care Plans need to be more thorough regarding medical checks, continence needs and cultural issues, and including the daily living wishes of residents. Staff need to read all Care Plans so that appropriate care is always delivered. Food needs to be supplied in line with residents cultural preferences and be recorded in food records to evidence this. Staff need to be aware of the full Vulnerable Adults procedure. The refurbishment of the home needs to be completed and to ensure proper locks to residents doors are fitted. Two written references need to be received before staff commence employment. Staff training on all relevant issues needs to be supplied. A Quality Assurance system needs to be in place to check all services to residents. 2. OP15 3. 4. 5. 6. 7. OP18 OP19 OP29 OP30 OP33 Crown Hills Nursing Home DS0000001897.V368203.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Crown Hills Nursing Home DS0000001897.V368203.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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