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Inspection on 11/09/07 for Amberley Nursing Home

Also see our care home review for Amberley Nursing Home for more information

This inspection was carried out on 11th September 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Registered Providers had provided a statement of purpose and Residents Guide to the Home, and all new Residents applying to the Home would be appropriately assessed by the Deputy Manager before an admission was arranged. The Deputy Manager and staff were found to be attentive and supportive of the Residents, and completed a good level of administration to support this level of care. The Resident spoken with also said how helpful staff were, which was observed during this visit to the Home. Residents were found to be well protected by the Complaints procedure and the Safeguarding Adults procedure in the Home. The Home was found to be well maintained throughout. Very good levels of care staffing were provided to meet the needs of all Residents. The majority of the administrative arrangements to ensure that the Home met the standards set by law were found to be in place.

What has improved since the last inspection?

This Home was last inspected on 7 November 2006. Since that time the Home has improved in a number of ways, which are listed below: Residents care plans are now maintained to a better standard, and staffing numbers are now much better managed. When new staff are employed the Deputy Manager now ensures that all necessary documentation is obtained. Training has been provided in Safeguarding Adults.

What the care home could do better:

At this visit to the Home it was found that the following improvements were needed: The Registered Providers needed to ensure that the Residents Guide was updated to include all of the details listed in the legal amendment made in September 2006. The Registered Providers were also encouraged to improve some of the information provided in the Residents Guide, and to provide a copy of it that could be accessed by Residents themselves. The information contained in each Residents care file needed some improvement to ensure it met the Standards and Regulations. Staff were encouraged to improve the way they helped those Residents who needed assistance when eating their meals. A small number of physical improvements were needed in and around the Home to maintain a good standard for the Residents. The Registered Providers needed to ensure that at least 50% of all care staff held an NVQ level 2 in Care at all times. The Registered Providers also needed to appoint a new Manager to the Home as soon as possible. The Deputy Manager needed to ensure that all care staff were appropriately supervised. The majority of mandatory training had fallen behind the necessary time schedule. This needed to be urgently addressed, as it was noted as needing attention at the last inspection in November 2006. Various pieces of equipment used in the Home needed servicing.

CARE HOMES FOR OLDER PEOPLE Amberley Nursing Home Off Cedar Close Eckington Sheffield Derbyshire S21 4BA Lead Inspector Steve Smith Key Unannounced Inspection 11th September 2007 09:30 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 Amberley Nursing Home DS0000002035.V345440.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. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amberley Nursing Home Address Off Cedar Close Eckington Sheffield Derbyshire S21 4BA 01246 436850 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) Enable Care & Home Support Limited Vacant Care Home 15 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (15) of places Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: Amberley House Nursing Home provides nursing and personal care for up to fifteen Older People with Learning Disabilities, aged over 65 years, and for up to 5 people with Learning Disabilities aged under 65 years. The Home is situated on the edge of the north-east Derbyshire boundary within the village of Eckington. It is close to shops, a post office and all local amenities, and near to a direct bus routes to both Chesterfield and Sheffield. The Home aims to provide an holistic approach to care and to promote the Residents dignity and choice. It also aims to provide a good quality of life for its Residents within a friendly and homely environment. The Home provides single bedroom accommodation on the ground floor. There is a large lounge and one dining room and an additional smaller lounge area, that has been built to provide a quieter area for residents. There is adequate toilet and bathing provision, with suitable adaptations and equipment provided. There is access to a garden/patio area with seating provided for Residents. Nurse cover is provided at all times by Registered Nurses (Learning Disabilities) and there is a team of care and domestic services support staff. The charges made for a room at Amberley House is £1141.00 a week. This charge is made for all Residents. A copy of the Commission’s inspection report is available from within the Home. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of just under 7 hours. Discussion was held with one Resident, and the records of two Residents were ‘case tracked’. Discussion was also held with one of the Deputy Managers and with one member of the care staff. A number of records were examined, and the bedrooms of all Residents were examined, and all public areas of the Home were looked at. The Commission’s Annual Quality Assurance Assessment questionnaire, sent to the Deputy Managers, was examined. The Commission’s Residents questionnaire was also sent to a selection of Residents, and all 10 were returned at the time of this inspection. They all commented most favourably on the Home. What the service does well: What has improved since the last inspection? This Home was last inspected on 7 November 2006. Since that time the Home has improved in a number of ways, which are listed below: Residents care plans are now maintained to a better standard, and staffing numbers are now much better managed. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 6 When new staff are employed the Deputy Manager now ensures that all necessary documentation is obtained. Training has been provided in Safeguarding Adults. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 & 6. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they and their families were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a statement of purpose for the Home together with a Residents Guide. However, although the documents were well completed, neither document contained information about the physical environment Standards addressed in the Home. The Residents Guide also did not include the new issues listed in the Regulations that came into force in September 2006, nor did it contain the opinions of Residents on what life was like in the Home. The Residents Guide was also not available in a format that could be easily understood by the Residents in the Home. However, the Guide did contained information on how contact could be made with the Commission, the local Social Services Dept and the local Health Authority. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 9 The records of two Residents were examined during this inspection and a copy of the statement of terms and conditions of residency was available with the Home. When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident, copies of which were seen. The Manager also assessed all Residents sponsored by Social Services Depts. If the Residents were self-funding from the outset, the Manager completed her own summary of needs, although the Home was not supporting any Residents who where self-funding at the time of this visit. Standard 6 does not apply to this Home. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 &10. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being well met, as demonstrated within care plans, and medication was administered appropriately to meet Residents needs. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of two Residents were examined, for the purpose of case tracking. Most of the basic information, concerning each Resident, was found to be in the files examined. That was, their name and date of birth, their next of kin, their GP, and their date of entry to the Home. However, both files had no record of the preferred name of each Resident, and one file had no record of the name of the Social Services Dept Care Manager. Neither of the records of the Social Services Dept initial assessment, or the Manager’s initial assessment of each Resident could be found in the Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 11 files examined. However, comprehensive plans of care were available in each file, together with the risk assessments on each Resident. There were also no records, for the Resident suffering with dementia, of the Resident’s possible limitations of choice, freedom and decision making ability. These records should at least be updated at the time of the formal 6 monthly reviews. Annual reviews of care were found completed by Social Services Dept, but none by the Home. The Resident, their relatives or formal representative, should all be invited to these formal 6 monthly reviews. Both of the files were easy to read and good entries had been made by the nursing staff. The Deputy Manager said that she reviewed the records of each Resident at regular intervals, but she had not signed the records to indicate that this had taken place. The files were well organised, with different sections, although a confidential records section was not found in any of the files examined. Each file did have an activities, which list the activities provided for each Resident. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents was examined, and a good system was found to be in use. Discussion was held with a Resident about life in the Home. She said that staff were generally very good at listening to her views on how she liked to be cared for and staff would carry out her wishes. She also said that her care needs were, again in general, always met with dignity and respect. As a result, she felt very safe in the Home, and appeared to have a strong sense and appearance of well being – ‘Staff help me to do everything, and they are very kindly. I can use the bell pull in my bedroom and staff come and help me.’ Discussion was also held with Staff, and very positive ways were described of assisting Residents within the Home. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 12 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 & 15. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home. Residents were given a wholesome and appealing diet in pleasant surroundings. EVIDENCE: The Resident spoken with was asked about the activities provided in the Home. She said that a number of activities were provided, giving the following list; TV watching, jigsaw making, going out shopping, shopping for holidays, day trips are provided and the Salvation Army calls to provide services. Staff were asked about this and they added that an Activities Coordinator arranges all activities. As well as those listed by the Resident, staff said that the Coordinator also arranges raffles, tombola, trips to local fairs when they visit, plus other regular trips out from the Home, two a month. The Resident spoken with said that she decided when she got up and went to bed – ‘I say when I want to got to bed and I say if I don’t want to get up.’ She also said that she has a bath most nights of the week. Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘I can see my (relative) in my bedroom or in the Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 13 lounge.’ The staff spoken with also said that relatives could visit at anytime, and could be seen by the Residents in one of the lounges, or in their bedrooms. The Resident was very clear that when staff knocked on her bedroom door to come in, they always waited for her to say ‘come in’ before doing so. The Resident spoken with said that the Home provided a choice on the menu at every meal provided in the Home. Staff spoken with confirmed this and said that drinks and snacks were always provided between meals for Residents, which was witnessed during this visit to the Home. Staff said that when Residents needed to be fed by the staff, that, for example, all of these Residents were fed with their dinner, and then all Residents would be feed with their sweet/pudding. The result of this was potentially a long period of time between each part of the meal. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 14 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 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints made to the Registered Provider or Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: The Resident spoken with said that if she was not satisfied with something in the Home she would tell either the staff or the Deputy Manager – ‘I had to complain about another Resident and (the Deputy Manager) helped to sort it all out.’ The Commission had not received any notice of complaint since the last visit to the Home, in November 2006. The Deputy Manager said that there had been no formal complaints since November last year, and that the concerns of Residents and their relatives were recorded in Residents files and resolved in a very short period of time. Good procedures were seen for both written and verbal complaints. The Registered Providers complaints procedure detailed that all complaints would be responded to by the Registered Providers or Manager within at least 28 days. The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy, of which staff spoken with were aware. The Deputy Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 15 Manager said that a copy of the Dept of Health’s policy called ‘No Secrets’ was available in the Home, but not that of the Public Interest Disclosure Act 1998. The Deputy Manager also confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be recorded. However, she reported that this had not needed to be used for some time. The policies and practices laid down by the Registered Providers ensured that all staff understood physical and verbal aggression by Residents. The Deputy Manager said that a policy was not available to staff stating that they could not benefit from Residents wills. A staff member spoken with was also unaware of this. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 16 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, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was very well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the public areas of the Home, and all the bedrooms of the Residents. The Home was attractively decorated throughout, and the lounges and dining room were pleasant to sit in, and were provided with appropriate items for the Residents. The bedrooms provided very good space and provision for each Resident. The Registered Providers had provided almost all of the furnishings required in all locations seen during this visit. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 17 Toilets were easily available to all Residents, were clearly marked, and were provided with handrails where necessary. A call system was also available throughout the Home. All bedroom doors were provided with locks, which Residents could chose to use. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. However, the following issues needed attention: The main light in most rooms was provided by a 60 watt light bulb rather than 100 watt light bulb. Many bedrooms also had upward facing light shades, which also reduced the lighting in the bedrooms. Lighting to 150 Lux (approximately 100 watts) must be provided in each bedroom. This must be addressed by 6 November 2007. The door to the smaller of the two toilets, at the end of the lounge, did not close and needed attention. This must be addressed by 6 November 2007. In all bedrooms only one comfortable seat was provided, and not the two comfortable seats recommended by National Minimum Standard 24.2. Toilets in the Home were very clean and tidy, but were very clinical in appearance. It was recommended that the toilets be made more ‘homely’ in appearance. In a number of bedrooms Kings Fund beds were provided, which were very mechanical and unattractive in appearance. It was suggested that more ‘homely’ beds be provided such as ‘profile beds’ Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 18 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): Standard 27, 28, 29 & 30. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. A good level of care staffing was provided to meet the needs of Residents, and appropriate recruitment practices were always followed when recruiting new staff, so that Residents welfare was always safeguarded. EVIDENCE: A very good level of staffing was found to be provided in the Home to meet the needs of Residents. At the time of this visit to the Home it was found that under 50 of care staff had a qualification of at least NVQ level 2 in Care: 2 out of a total of 18 care staff. However, the Deputy Manager was able to say that a further 7 staff were currently taking the NVQ level 2 course, and it was anticipated that they would have completed their courses, with passes, by August 2008, at the latest. Since the last visit made to the Home in November 2006 only one new member of staff had been employed. The records of this new member of staff were examined to see whether the Manager/Deputy Manager had obtained all relevant information about her, and it was found that all information had been obtained. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 19 The Deputy Manager said that new staff would be provided with induction and foundation training, which was confirmed by staff. She also said that all care staff were provided with at least three paid days training a year. A member of the care staff said that all training was paid for by the Registered Providers. The records of some of this training was seen. All staff also had an individual training and development assessment and profile. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 20 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 & 38. The quality in this outcome area was Adequate. This judgement was made using available evidence including a visit to this service. Management arrangements at the Home were not sufficiently robust to ensure that residential care was maintained at a positive standard. EVIDENCE: At the time of this visit to the Home no Manager was in place, as the previous Manager had left, due to ill health. This situation had been in place since January 2007, and needed to be urgently resolved. The Registered Providers were found to be ensuring that the formal ‘inspections’ of the Home, as required by Regulation 26, were carried out. The Deputy Manager was able to show the annual development plan for the Home that reflected the aims and outcomes for Residents. She was also able Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 21 to show the results of Residents surveys, and the results of relative surveys, both of which were posted on the Home’s notice board. The Manager was able to show that the personal money of Residents, held by the Home, was maintained satisfactorily. While reviewing Residents personal money a number were found to need revising to a more suitable amount to be kept in the Home. A staff member was asked about the regularity of supervision, and the staff member said that this was not provided. This was later confirmed by the Deputy Manager, saying that since the Manager had left only very rudementary supervsion had taken place in the Home. The training required by the Regulations was examined. This showed that Fire Safety training had been provided for all staff. However, annual Moving and Handling training was needed by all staff, and First Aid training was also required by 11 staff. Food Hygiene training was still required by 3 staff, and at least 13 staff required Infection Control training. A staff member spoken with confirmed this need for training. However, the Deputy Manager also said that additional training had been provided for staff on Adult Protection, Continence, Epilepsy, Makaton, Dysphasia, Supervision, NVQ and chair based exercises. From the copy of the Home’s maintenance schedule, forwarded to the Commission prior to the inspection, it was found that the servicing of the emergency call system was out of date, having last been done in March 2006; the heating system was also out of date, having been last serviced in October 2005, and gas appliances were also found to be out of date, having also last been serviced in October 2005. The Deputy Manager was able to show that the Home had complied with the majority of legislation applicable to its operation, although she said she did not have information on the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations of 1992 or the Provision and Use of Work Equipment Regulations of 1992. The Deputy Manager was able to show that risk assessments had been provided on the working conditions of staff; that is for care staff, catering staff and domestic staff. She was also able to show that a written statement of the policy, organisation and arrangements for maintaining those safe working practices had been provided. Finally, the Deputy Manager was able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 5 Requirement The Residents Guide must contain all the information outlined in the up dated Regulation 5 provided in the legal amendment made in September 2006. Residents files must contain the name of the designated Care Manager and the Social Services Dept who arranged the admission of the Resident. The Deputy Manager needs to ensure that each Resident suffering with dementia, or their representative, has had the opportunity to discuss their rights of choice, freedom and decision-making while staying in the Home. The outcome needs to be recorded in each Resident’s records, as they deteriorate, at least on a 6 monthly basis. A number of Requirements must be addressed in and around the Home, details of which are including in the section headed Environment Standards 19 – 26. DS0000002035.V345440.R01.S.doc Timescale for action 06/11/07 2. OP7 17(1)(a) and Sch 1, 3(c) & (h) 17 & Sch 3, 3(q) 06/11/07 3. OP19 12, 13 & 23 06/11/07 Amberley Nursing Home Version 5.2 Page 24 4. 5. OP36 OP38 18(2) 18(1)(c) (i) Time schedules for this items are also provided in the above section of the report Supervision must be provided for all care staff. Mandatory training must be provide for all necessary staff in Moving and Handling, First Aid, Food Hygiene and Infection Control training. (This issue is outstanding from the inspection report dated 7 November 2006) Servicing of all equipment, fixtures and fitting in the Home must be provided. Namely, the emergency call system, the heating system and gas appliances must all be regularly serviced. 06/11/07 28/02/08 6. OP38 23(5) 06/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 No. 1. Good Practice Recommendations The statement of purpose should contain information on the physical environment Standards met/not met, and be summarised in the Residents Guide. The Residents Guide should contain information obtained from Residents (or their relatives) on what the Home is like to live in. Residents should have available to them a copy of the Residents Guide, laid out in a format they would be able to understand, when supported by staff. 2. OP7 Residents files should record the preferred name of each DS0000002035.V345440.R01.S.doc Version 5.2 Page 25 Amberley Nursing Home Resident, and the name of the Social Services Dept Care Manager. Formal reviews of care should be undertaken at 6 monthly intervals. Those taking part should at least include staff from the Home, the Resident and their relatives, particularly the ‘personal representative’. The review of care should be shown to the Resident (or representative) for signature. One of these reviews, each year, could be conducted by the Social Services Dept, although the Manager should provide formal written input to the review of the welfare and care provide to the Resident. When the Deputy Manager has reviewed a Resident’s file, she could indicate that this has been done by signing the record with a red or green pen. Each Resident’s file should contain a ‘confidential’ section. This section should be used for records made by staff that the Resident should not see and for information passed to the Home by professionals to which the Resident had not been made party. 3. OP15 Residents who needed assistance with eating should be given both their dinner and sweet/pudding together, to avoid a long period of time elapsing between each part of the meal. Residents waiting to be assisted with their meal should be left in the lounge, until staff could assist them with all their meal. Where these Residents were slow to eat, the meal should be reheated at least twice before accepting that the Resident does not want to complete the meal. A copy of the Public Interest Disclosure Act 1998 should be obtained and be available in the Home at all times. A policy should be provided stating that staff cannot assist in the making of or benefit in anyway from Residents wills. 5. OP19 to OP26 A number of Recommendations should be addressed in and around the Home, details of which are including in the section headed Environment Standards 19 – 26. At least 50 of care staff should hold an NVQ level 2 in Care by the end of August 2008. At least 50 of care staff need to hold this qualification at all times the Home is in operation. 4. OP18 6. OP28 Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 26 7. 8. OP31 OP35 A new Manager should be urgently appointed to manage the Home. The amounts of Residents personal allowance kept within the Home should be reduced to the amounts suggested during the visit made by the Inspector. The Deputy Manager should arrange for all care staff to receive supervision at least 6 times a year. The Registered Providers should ensure the Home complies with the Management of Health and Safety at Work Regulations 1999, the Workplace (Health, Safety and Welfare) Regulations 1992 and the Provision and Use of Work Equipment Regulations 1992. 9. 10 OP36 OP38 Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Amberley Nursing Home DS0000002035.V345440.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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