Inspection on 27/04/05 for Aquarius Nursing and Residential Care Home

This inspection was carried out on 27th April 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

Aquarius Nursing and Residential... 10/03/09

Aquarius Nursing and Residential... 25/09/08

Aquarius Nursing and Residential... 07/05/08

Aquarius Nursing and Residential... 23/04/07

Aquarius Nursing and Residential... 14/09/06

Aquarius Nursing and Residential... 09/05/06

Aquarius Nursing and Residential... 28/09/05

Aquarius Nursing and Residential... 02/11/04

Aquarius Nursing and Residential... 29/06/04

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Hillyfield Rest Home

The Maypole Nursing Centre

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

CARE HOMES FOR OLDER PEOPLE Aquarius Nursing & Residential 4 Spencer Road Southsea PO4 9RN Lead Inspector Jan Everitt Unannounced 27 April 2005 9:30 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. Aquarius Nursing & Residential Care Home Version 1.10 Page 3 SERVICE INFORMATION Name of service Aquarius Nursing & Residential Care Home Address 4 Spencer Road, Southsea, Hampshire, PO4 9RN 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) (023) 92 811824 Qualitycare Management Limited Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (38), Old age, not falling within any other category (38), Terminally ill over 65 years of age (26) Aquarius Nursing & Residential Care Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Staffing notices apply Date of last inspection 2/11/04 Brief Description of the Service: The Aquarius Nursing Home is a care home providing nursing care for 38 older people over the age of 65 years who suffer from mental frailty, mental disorder, excluding learning disabilities. The home is also registered to accommodate 26 older people with life limiting diseases. The Aquarius is the only care home owned by Quality Care Management Ltd. The home is located in a residential area of Southsea, close to the sea front and the local amenities of the city of Portsmouth. The home consists of three large houses that have been joined together to the effect of a large town house. The service user accommodation is located over three floors. There is a pleasant courtyard at the front of the house and a patio area at the rear for service users to use in the finer weather. Nine of the eighteen single bedrooms have en-suite facilities. There are ten double rooms seven of which have en-suite facilities. There is a passenger lift fitted from the ground floor to the first floor only. Chair lifts are in place on some of the other flights of stairs that access other floors. Rooms that have been identified as having only access via a flight of stairs can only accommodate service users who are fully mobile. Aquarius Nursing & Residential Care Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of the Aquarius Nursing Home took place on the 27 April 2005. Owing to the issues highlighted in previous inspections and those identified at this inspection the process was lengthy and took 9 hours. The responsible individual, Mrs. Lightwood and the senior nurse on duty, Mrs. Sharon Tucker, assisted with the inspection process. The inspector was informed that the home had been without a manager for the past six weeks owing to the registered manager being on long term leave. The inspection identified that of the 21 National Minimum Standards assessed on this occasion 15 of which were the key standards, 11 had been met, 5 had minor shortfalls and 5 had major shortfalls. The standards not met have been discussed with Mrs Lightwood and are identified in the main body of the report and letter has made immediate requirements to action. Given the issues raised in this report, the responsible individual will be formally asked to meet with the CSCI regulation manager. Comment cards from the CSCI were distributed to a number of relatives who were visiting the home at the time of the inspection and to one service user. A number of service users were spoken with who reported satisfaction with the services in the home. Due to service users mental frailty it was not always possible for the inspectors to gain accurate information and opinions about the care provision in the home, therefore relatives were spoken with to enable the inspector to form judgments about the home. A number of staff were spoken with who spoke positively about their employment. What the service does well: The home cares for a group of service users with complex care needs. The assessments and care plans are well documented. All service user and/or their relatives are requested to provide the home with a pen history of the individuals past life and interests which helps identify service users’ needs and therefore plan care around these needs. Relatives are invited to be involved in the care planning process. The home provides a nutritious diet and meals that are served three times a day. The senior nurse has devised an efficient system for the ordering, storing and administration of medication to ensure that stock levels remain within safe limits and that medicine charts are documented consistently. The home welcomes visitors and relatives who visit the home during the course of a day. The home is making efforts to maintain a redecoration programme and the replacement of furniture in the bedrooms and lounges. Aquarius Nursing & Residential Care Home Version 1.10 Page 6 Service users health care needs are met. What has improved since the last inspection? What they could do better: The home should produce an accurate Service User Guide that would aid service users and relatives to make an informed decision about entering the home. The responsible individual must be aware to respect the privacy and dignity of the service users at all times and not display on a board in view of other service users and visitors, information and judgements as to service users’ mental capabilities. A phone facility should be made available to service users to enable them to make and receive calls in private. The home should employ an activities organiser to plan and undertake appropriate activities for elderly people with mental frailty. The home does not have sufficient assisted baths to enable service users to have a bath as and when they choose. Radiators and exposed pipe work in areas used by the service users remain exposed. There will be a requirement in this report for this to take priority on the maintenance programme. Baths and showers have not been fitted with thermostatically controlled valves and this will be a requirement in this report. Domestic type lighting has not been fitted to the four bedrooms on the second floor. Staffing levels must be increased. There is consistently insufficient staff on duty at all times to meet the needs and safety of the service users. An immediate requirement has been made from this report. Service users must not have long gaps between their last food of the day and that of their breakfast and should not be more than 12 hours apart. The recruitment process is badly flawed. The personnel files evidenced lack of information and CRB and POVA checks on staff recently employed. The responsible individual has not informed the CSCI of the registered managers absence and of the management arrangements in place whilst he is absent from the home. Polices of the home must be reviewed and updated. Records of fire training and mandatory training could be recorded on a training matrix to identify who has had training and who is in need of updates. Aquarius Nursing & Residential Care Home Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Aquarius Nursing & Residential Care Home Version 1.10 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 Aquarius Nursing & Residential Care Home Version 1.10 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) 1,3,& 4 Prospective service users and their representatives do not receive all information available to make an informed decision about living in the home. Service users needs are assessed prior to admission to the home. Service users needs were not being met fully at the time of the inspection. EVIDENCE: The home has a Statement of Purpose, a copy of which is in each service users’ room. A Service User Guide is not available to service user prior to admission to the home. The responsible individual reports that they are in the process of being printed. Mrs. Lightwood, the responsible individual, and a trained nurse assesses the potential service users needs prior to admission to the home. Care managers also share assessments with the home if they are involved in the placement. The assessment tool includes the activities of daily living. The home was not able to fully meet the needs of the service users at the time of the inspection because staffing levels were short by four carers that morning. This was evidenced by the inspector speaking with service users who Aquarius Nursing & Residential Care Home Version 1.10 Page 10 reported that 09.30 was late for their breakfast to be served but they assumed it was because the home was short staffed. One service user reported she had not eaten since 17.30 the previous evening. Aquarius Nursing & Residential Care Home Version 1.10 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 Service users health, personal and social care needs are set out in individual care plans. Service users health care needs are adequately met. Service users are protected by the policies and procedures that underpin the practices by the staff when dealing with medication. Service users right to privacy is not upheld at all times. EVIDENCE: Care plans are in place for all service users. The information generated from the assessments and a pen history of the service user’s life forms the basis for the plans. The system is fragmented and information kept in different files. The senior nurse reported that the acting manager will be introducing a new system once she is officially in post. The proposed new system was discussed with the inspector. Care plans are reviewed monthly and there was evidence of signatures of service users/relatives of their involvement and agreement to the plan of care. The one service user with a reported pressure sore was being nursed on a pressure-relieving mattress. The provider reported that the dentist visits the home regularly to adjust dentures and undertake dental care. Service users use the community optician but one does visit the home if requested. Aquarius Nursing & Residential Care Home Version 1.10 Page 12 A chiropody service is available every 6 weeks. Nutritional assessments are not undertaken routinely but there was evidence in the care plans that weights are recorded at regular intervals on service users that are considered at risk. Service users were observed to be mobilising freely about the home and lounge area. Trained staff adhere to policies and procedures for the safe keeping and administration of medication. In the absence of the registered manager a senior nurse has taken responsibility for the coordination of ordering, checking and administration of all medicines. It was observed that an untrained nurse writes prescription sheets and this practice must cease. Stock cupboards and the medicine trolley were observed to be clean and tidy with no evidence of overstocking of drugs. A sample of three service users medication records was viewed and the balance recorded reflected the current stock at that time. The drug fridge temperatures were observed to be recorded daily. There were no service users choosing to self-administer their own medication. The senior nurse reported that GPs are requested by the home to review medication approximately every three months. Service users have personal care and are seen by other professionals in the privacy of their own room. There are no locks on any of the bedroom doors. This has been under discussion with the responsible individual who reports that service users’ families are resistant to locks being fitted on doors and the inspector evidenced a letter from a relative advocating this for the service user. The Service User Guide must stipulate that service users are given choice at to having a lock fitted to their bedroom door when they are admitted to the home and following a risk assessment, as to the safety of this. It was observed that not all rooms have a lockable storage facility but the responsible individual reported that lockable storage space would be provided if requested by the service user. Staff were observed to be treating the service users with respect and kindness. The inspector was requested by one service user to use her mobile phone. On further discussion it was observed that the service user was very agitated and upset. The inspector addressed this with the responsible individual who informed her that the lady was often like this and when the inspector suggested that she use the pay phone, was informed that there was no private phone for service users to use only the one in the office and that the senior nurse sometimes let the lady use her personal mobile phone. A requirement for action will be made around this issue. Whilst talking to a relative in the nurses’ office, which has glass walls and is open to service users and visitors, the inspector observed a large wipe board on the wall, with the service users’ names and details and judgements on their behaviour. This was discussed with the senior nurse as to the confidentiality and service users’ rights, she understood this but that she was not allowed to touch the board. This was further discussed with the responsible individual, who reported that this was how the carers judged how many carers were needed for each service user. An immediate requirement was made around the issues of confidentiality, privacy, dignity and the rights of the service users. Aquarius Nursing & Residential Care Home Version 1.10 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 The home was meeting the needs and expectations of the service users social, recreational and religious interests. Service users contact with their families/friends/ representatives and the local community is maintained to their own expectation and choice. Service users are able to exercise choice and control over their lives within their own capacity to do so. Service users receive a wholesome balanced diet but not always at times convenient to them. EVIDENCE: The home attempts to get a social history and past interests from relatives that will contribute to the care plan to fulfil their needs of social interaction. The senior nurse reported that for most of the service users in residence, it is difficult to communicate their needs and desires for activities. The home displays an activities sheet that informs of the activities for the week. An outside entertainer attends the home to play music that service users are invited to join in with their own musical instruments supplied by the home. The responsible individual reports that the home has no activities organiser and that carers undertaken this role. The lack of staff on duty at the time of the inspection would indicate that activities do not take place regularly and a recommendation will be made for the home to employ an activities organiser who has experience with working with older people with mental frailty. In the Aquarius Nursing & Residential Care Home Version 1.10 Page 14 afternoon the inspector observed a ball game being played with a group of service users and two carers assisting. The local vicar will visit the home and a church member will collect those service users wishing to attend the church in the community. There are restrictions within home life and the numerous notices around the home signed by Mrs. Lightwood, the responsible individual, reflect this. The home has a programmed bath rota for service users to bath once a week. This was discussed with the senior nurse as being restrictive and institutionalised; she reported that service users are able to have a bath more often if necessary or if it is requested but that many of the service users are unable to voice their needs and choices. Newspapers are arranged and delivered by the relatives. The home has books and magazines around the lounges. The home was evidenced to have many visitors throughout the day and the visitor’s book also supported this. The inspector observed on the front door two notices with references to visiting restrictions at mealtimes and one with reference to bringing infection into the home. These details should be documented in the service user guide and written into the visiting policy that should be available to all service users’ families. The inspector spoke with five relatives visiting that day. They all reported satisfaction with the care their relatives were receiving. One daughter reported that her only concern for her mother was that of a family dispute over finances but she was basically happy with the care in the home. Service users are unable to manage their own financial affairs and it was reported that relatives take on this responsibility. The inspector observed that some service users had bought pieces of their own furniture into the home to personalise their space, a record of this is maintained in their file. The menus are varied and on a four weekly cycle, which the chef reported is not always adhered to depending on various factors: These are displayed in the hallway. The daily menu is displayed on a chalkboard in the dining room and alternative choices are available if requested and by prior arrangement. On the day of the inspection six service users were waiting for their breakfast at 09.30. One service user reported that she had not eaten since teatime the previous day at 17.30. This was addressed to the responsible individual as being a too long a gap between meals. She reported that a supper of sandwiches and snacks are offered 20.00. A requirement will be made around these findings. A service user informed the inspector that toast and cereal was served most days for breakfast but a cooked breakfast is available on certain days of the week. Another service user described the food as bland and other service users reported they considered the food excellent. The senior nurse reported that snacks were available throughout the twenty-four hour period if requested. The inspector visited the kitchen before lunch and observed that the meal to be served that lunchtime looked to be wholesome and well presented. The inspector observed that a number of service users were in need of assistance with their eating. On the day of the inspection a number of staff had been requested to attend the home and by lunchtime Aquarius Nursing & Residential Care Home Version 1.10 Page 15 there were sufficient staff to meet the service users needs with assistance with their meal. Aquarius Nursing & Residential Care Home Version 1.10 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 home adheres to the complaints policy in place and service users/representatives are confident that their complaints and concerns will be recorded and responded to. The home has systems and policies in place to protect the service users from abuse. EVIDENCE: The home has a complaints policy, which is displayed on the wall in the hallway. The inspector viewed the complaints logbook that evidenced no complaints recorded. The inspector enquired of two relatives who they would speak to if they wished to complain or had concerns; they both reported they would speak to the senior nurse or the responsible individual. The home has the Hampshire Protection of Vulnerable Adults procedure. Staff have received training on abuse and how to identify and report incidences. Certificates of training were evidenced by the inspector in training files. No reports of abuse have been reported. Restraint in the form of bedrails is used in the home. A risk assessment is undertaken and permission sought from the service user or their representative for their use. Aquarius Nursing & Residential Care Home Version 1.10 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) 20, 21, 25 Service users have access to comfortable indoor and outdoor communal facilities. The home has sufficient lavatories and washing facilities but insufficient assisted baths to meet the needs of the service users. There are areas of the home that do not provide a safe, homely environment for service users. EVIDENCE: The home has three lounges and a separate dining room that has now been furnished with domestic type furniture. The responsible individual reported that there are plans to further extend the dining room and kitchen to include a new laundry area. The home has a pleasant outside courtyard with seating provided for service users to use in the finer weather. The home has only one assisted bath on the ground floor and four other bathrooms. More assisted baths are necessary for the number of service users. This issue has been discussed in the past two inspection reports and will be made a requirement of this report. There are sufficient lavatories and Aquarius Nursing & Residential Care Home Version 1.10 Page 18 the inspector observed that hand washing soap dispensers and disposable hand towels were being fitted in each of these facilities. The inspector observed that fluorescent lighting is fitted to four of the 2nd floor bedrooms without covers. Bedside lighting is supplied in these rooms but in rooms 16 and 18 bedside lamps were across the room from the bed. This was discussed with the responsible individual and requirements have been made in the past two inspection reports. A number of radiators in areas used by the service users remain uncovered. This has been a requirement of the past two inspection reports and will be made a requirement of this report. There are no thermostats fitted to the bath hot water taps. The inspector randomly checked the sink hot water taps and temperatures recorded were 42 degrees. The responsible individual reported that the temperature had been turned down at the boiler. The temperatures at which hot water must be stored to ensure purity were discussed with the responsible individual and the home must ensure that thermostats are fitted to bath and shower hot water outlets and hot water. There will be a requirement from these findings. Aquarius Nursing & Residential Care Home Version 1.10 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 The home is not maintaining adequate staffing levels over the twenty-four hour period to meet the needs of the service users The home’s recruitment policies and practices do not ensure the safety and protection of the service users. EVIDENCE: The inspector observed that there were only two trained nurses and two carers on duty on the day of the inspection to care for 38 service users. The explanation given was that one carer had gone sick and secondly new carers had not turned up for duty. Service users were waiting for breakfast at gone 09.30 and others were still awaiting their medication and assistance to dress. This was discussed with the responsible individual who reported that she would not employ agency staff to fill the gaps. The staffing rotas were examined. There were no actual hours worked by employees. Copies of staffing rotas with number of hours recorded have been requested in previous inspection reports and have again been requested on this occasion. An immediate requirement letter has been dispatched to Mrs. Lightwood with reference to the inadequate staffing levels. The home has a separate cleaning staff and adequate cleaning standards are being maintained. There is also a separate person in the laundry. The inspector examined a sample of recruitment files. One file had no references at all. The second file had only one written reference and the CRB/POVA check had been transferred from a previous employer. The third file did not have a POVA first check before employment commenced. Interview Aquarius Nursing & Residential Care Home Version 1.10 Page 20 records are not maintained and therefore no evidence that employees have been interviewed. Mrs Lightwood has employed an acting manager on a part time basis and who has another job. There was no evidence of any recruitment documentation i.e. application form, references, CRB/POVA application, this was discussed with Mrs. Lightwood who reported that the lady in question was a friend and she knew her well and she anticipates that she will take over the management of the home full time and become registered with the CSCI. The proposed acting manager reported to the inspector that she had not yet made a final decision on her employment at the home. A requirement will be made from these findings. Staff contracts were evidenced in the personnel files examined. An immediate requirement letter has been sent to Mrs. Lightwood to address what documentation is required prior to the commencement of employment. Aquarius Nursing & Residential Care Home Version 1.10 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, 33 & 38 The home is not being managed at the present time by a person who had been deemed fit to be in charge of the home and to take full day to day responsibility for meeting the needs of the service users in residence. The home does not have all the policies and procedures available to ensure that the home is run in the best interests of the service users. The health, safety and welfare of service users and staff are not always promoted and protected. EVIDENCE: The registered manager is absent from the home owing to serious illness. This has not been reported to the CSCI nor the management arrangements made in the interim. This was discussed with Mrs Lightwood and an immediate requirement letter has been dispatched requiring this information to be submitted to the CSCI. The home undertakes a satisfaction survey. The inspector viewed the results of a questionnaire sent out to relatives. The comments received were mostly Aquarius Nursing & Residential Care Home Version 1.10 Page 22 positive and indicated that there was satisfaction with the care their relatives received in the home. Mrs. Lightwood reported that issues and suggestions made in the comments had been actioned. Mrs. Lightwood’s personal assistant undertakes an audit of all housekeeping duties and ensures the home is clean. The senior nurse reported that she audits the medication charts to ensure records are maintained. The home is lacking in appropriate policies and a requirement will be made to review all policies of the home. The home has a fire risk assessment that is undertaken by a member of staff. The fire logbook was examined and the appropriate tests of equipment are recorded as taking place. The inspector could not evidence that all staff had undertaken fire training twice a year. The inspector viewed invoices for the servicing of systems and equipment. The five-year electrical wiring safety check has not been undertaken and this has been required in the last two inspection reports. The inspector viewed the report from the Environmental Health Officer who visited the home in January 2005; the responsible individual reported that the recommendations made from the report have been complied with. Aquarius Nursing & Residential Care Home Version 1.10 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION x 3 2 x x x 1 x STAFFING Standard No Score 27 1 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 1 x 2 x x x x 2 Aquarius Nursing & Residential Care Home Version 1.10 Page 24 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. Standard OP1 Regulation Reg 4(1) Sch 1 Requirement The Service User Guide must be available for all potential service users and/or their relatives A copy of this document must be submitted to the CSCI within stated timescales.. You are required to make suitable arrangements for the provision of telephone facilities which are suitable for the needs of the service user and for such facilities to be used in private. You are required to remove private, confidential information and judgemental comments from the notice board on view to other service users and visitors. You are required to ensure that service users do not have more a 12 hours gap between their evening meal and their breakfast the following day. You are required to install more assisted baths in sufficient numbers to meet the needs of the service users. This has been a requirement of the past two inspection reports. You are required to fit domestic type lighting in the four Version 1.10 Timescale for action 30/6/05 2. OP10 Reg 16(2)(b) 30/6/05 3. OP10 Reg 12(4)(a) 6/6/05 4. OP15 Reg 16(2)(i)(4 ) Reg 23(2)(j) 6/6/05 5. OP21 30/6/05 6. OP25 Reg 23(2)(p) 30/6/05 Aquarius Nursing & Residential Care Home Page 25 7. OP27 Reg 18(1)(a) 8. OP29 Reg 19(1)(b)(i )Sch 2 9. OP31 Reg 38(2)(3)( 5) bedrooms which have flourescent lights fitted. This was a requirement from the last two inspection reports and must be complied with. Bedside lighting in these rooms must be beside the bed and not on the opposite side of the room where it is not accessible to the service users. You are required to ensure that .6/6/05 sufficient and appropriately trained staff are on duty over the 24 hour period, taking into account the numbers and dependancy of the service users in residence. This has been a requirement of the last two inspection reports and an immediate requirement letter was sent to the responsible individual within 48 hours of the inspection. You are required to submitt to the CSCI copies of staffing rotas every week with full names of the staff and actual hours worked You are required to ensure that 6/6/05 all information required and stated in Sch 2 to be obtained during the recruitment process is contained in personnel files. Two written references must be obtained before staff can commence working in the home and proof that a CRB check has been applied for and the POVA first check has been obtained before staff can commence employment. CRB and POVA checks must not be accepted from other employments... You are required to inform the 6/6/05 CSCI immmediately of the absence of the registered manager and the arrangement Version 1.10 Page 26 Aquarius Nursing & Residential Care Home 10. OP33.9 Reg.10, 12 Reg. 13(4)c 11. OP38 made for the management of the home during his absence. Polices and procedures for home 30/8/05 must be reviewed to ensure practice guidance is available to all staff. The five-year electrical wiring 30/6/05 safety check must be undertaken and evidence of this taking place submitted to the CSCI within the stated timescales This has been a requirement of the last two inspection reports and must be complied with. 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. Refer to Standard OP12 OP7 OP32 OP38 Good Practice Recommendations It is recommended that an activities organiser be employed specifically to organise appropriate activities for the service users in residence. It is recommended that service users care plans and associated documention be centralised into individual service users files. It is recommended that the notices pinned to walls and notice boards around the home that appertrain to staff should be removed and written into policies for the home. It is strongly recommended that a matrix be created to document all the mandatory training that has taken place in particular fire training. This will enable the home to identify who has not received the appropriate training annually. Aquarius Nursing & Residential Care Home Version 1.10 Page 27 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI Aquarius Nursing & Residential Care Home Version 1.10 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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