Inspection on 22/06/06 for Arden Lea Nursing Home

This inspection was carried out on 22nd June 2006.

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 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

Arden Lea Nursing Home 21/04/09

Arden Lea Nursing Home 08/04/08

Arden Lea Nursing Home 12/04/07

Arden Lea Nursing Home 19/12/05

Arden Lea Nursing Home 24/02/05

Arden Lea Nursing Home 03/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Arden Lea Nursing Home 25 Mayo Road Sherwood Rise Nottingham NG5 1BL Lead Inspector Unannounced Inspection 22nd June 2006 10:00 X10029.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 Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 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 and Care Homes for Adults 18 – 65*. 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. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Arden Lea Nursing Home Address 25 Mayo Road Sherwood Rise Nottingham NG5 1BL 0115 9621100 0115 9113292 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) Mr Nimalendra Atheray Mrs Lesley Ann Wright Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (4), Terminally ill (2) of places Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19/12/05 Brief Description of the Service: Arden Lea is a 27-bed home situated close to the city centre with many local amenities and well served by local transport. All areas of the home are accessible to service users. The home provides 24-hour care with nursing for older people but 4 places may be used by people with a Physical disability between the ages of 18 and 65 years. The current weekly fees are as follows: £302 - £450 this is dependent upon needs and the nursing determination. Fees are discussed at the time of enquiry. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and thus the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. The unannounced site visit took place in four and a half hours and was performed by one inspector. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of three randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Five service users were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The manager, despite being off work at present came into the home and assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job role. What the service does well: A kind and caring ethos was prevalent throughout the home. Staff were observed to undertake meaningful interaction with service users. Service users spoken with were happy with life within the home and stated that anything they ask for is provided and staff are caring and respectful at all times. Staff spoken with were aware of service users needs and discussed how they facilitate these, they were able to discuss issues of adult protection to a good standard. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Whilst it is recognised that service users care plans continue to develop it is required that all service users with bedrails in place have appropriate risk assessments in place with regards to entrapment to ensure service users are protected. Once service users have undergone risk assessments for accidents a management plan outlining how the risk will be reduced and managed is required. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 7 Service users reviews are required to be service user focussed in order to reflect care and condition and aid consistency of care offered. It is recommended that all hand written entries on service users medication chart are signed by two members of staff to demonstrate that these have been checks and are correct thus ensuring service users are further protected. The responsible individual is required to liaise with the environmental health officer in order to implement safer systems of working thus protecting service users. All staff employed are required to have all documentation as listed in schedule 2 in place to ensure service users are further protected. It is recommended that further consideration is given to the décor in order to offer a more comfortable and pleasing environment for service users. It is recommended that staff continue to work towards attaining the national vocational qualification level two. All staff criminal record bureau checks are required to be undertaken by the home, to further protect service users. Evidence is required to demonstrate that staff have undertaken mandatory training in order to substantiate that staff are trained and competent to carry out their job role. Quality assurance systems are required to be implemented to demonstrate that the home is being run in the best interest of service users. Evidence to demonstrate that required safety checks and maintenance has been undertaken is required to substantiate the health safety and welfare of service users and staff is protected. All service users are required to have photographic identification (with consent) in place in accordance with schedule 4 to further protect service users. The responsible individual is required to liaise with the fire authority to ensure safe systems of work are implemented thus protecting service users and staff. Evidence of water temperature is required to demonstrate that service users are protected form the risks of scalds. 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. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 OP 2YPD The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users may be assured that their needs will be assessed and met prior to moving into the home. EVIDENCE: The manager visits prospective service users in the community and carries out preadmission assessments. The assessment in use cover the requirements of the standard, these assessments are also adapted according to service users needs. There was evidence available to substantiate this within service users files. The manger stated that prospective service users may visit the home and spend time there prior to making a decision. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 OP 6,9,16,18,20YPD The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. Service users needs are set out in an individual plan of care, however further attention is required with regards to risk assessments and the management put in place to reduce the risk to ensure service users are fully protected. Whilst service users reviews are undertaken further attention is required to ensure they are service user focussed to reflect care and condition. Service users health care needs are met. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 11 Service users are protected by the homes medication policies and procedures however minor attention is required with regards to hand written entries to ensure service users are fully protected. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Service users undergo various assessments such as manual handling, the daily activities of living, nutrition, pressure area care and social needs. Information gained underpins the plan of care. Care plans in place were personalised and reflected service users needs and preferences. Service users undergo an assessment of risk, however within care plans case tracked there were no management plans with regards to reducing and managing the risk available. One service user had a risk assessment in place with regards to falls. All service users case tracked were using bedrails; a risk assessment was in place with regards to falling out of bed, however there was no risk assessment in place with regards to entrapment. There was evidence to demonstrate that service users and relevant others had been involved in the plan of care. Care plans were in place with regards to social care needs and family involvement. Communication records were maintained and significant events were noted. There was evidence available to demonstrate that the multidisciplinary team and specialist services are accessed as required and relevant equipment was in place. One service user spoken with stated that they are able to see the doctor if required and staff would contact him. Service users spoken with stated that their needs were met. Staff spoken with were able to discuss service users needs. An appropriate medication policy is in place. Those service users case tracked prescriptions were checked against the medication chart and these corresponded. Medication received into the building and returned is logged appropriately. Medication charts were handwritten, whilst these were clear there were not two staff signature available to demonstrate these had been checked as correct. The manager stated that staff are instructed to maintain service users privacy and dignity and there are plans to involve an advocate to enhance this process. Staff were observed to treat service users with respect and maintain dignity at all times. Service users spoken with stated that staff were respectful and their privacy was maintained. Staff spoken with were able to discuss the core values and principles. Visitors may be received in private should they wish. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15OP, 12,13,15,17YPD The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. Service users are enabled to find the lifestyle in the home matched their expectations and preferences; it will be of benefit once the manager has implemented further activities for some service users. Service users are enabled to maintain contact with relevant others. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome and appealing diet in pleasing surroundings; however further attention in respect of the records maintained in the kitchen is required to ensure service users are fully protected. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 13 EVIDENCE: The routine of the home is stated by staff to be flexible and service users may choose when they get up and retire and how they spend the day. Service users spoken with substantiated this. There are activities on offer at present however these are limited, the manager is currently working towards improving these. Two service users spoken with stated they were happy with the amount of activities on offer whereas two others felt that more was needed to keep them occupied. Some service users attend day centres and one service user stated that they enjoyed this and staff helped them to get ready. Service users are enabled to visit the local churches if required and services are also offered within the home. There are no restrictions imposed upon visiting and visitors may be received in private. Two service users spoken with stated they receive regular visitors and they are made welcome and they often go out with them. All consultations are carried out in service users own rooms. Service users spoken with stated that they are offered choices with regards to the care and services received. All stated that staff listen to them and accommodate their requests. There was evidence within care plan to demonstrate that choices and preferences are maintained. With regards to equality and diversity staff were able to discuss how this is embedded into the ethos of the home. Service users are able to bring in personal possessions should they wish and one service users spoken with substantiated this. All service users spoken with stated that food offered was at a good standard and choices were offered. The menu observed was wholesome and appealing. The manager stated that specialist diets are catered for and the dietician was contacted if needed. There was evidence of nutritional assessments and dietician input in service users plans of care. One service user of an ethnic origin has a special delivery of an ethnic meal once a week, which they stated they enjoyed. Staff were observed to assist service users with their meals in a dignified manner. On observation the kitchen was clean and tidy, records with regards to temperature control and food service users had eaten was available, however there were no other records available. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18OP, 22,23YPD The quality rating for this outcome area is adequate this judgement was made using evidence available including a visit to the service. Service users and their relatives may be assured complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse, however further attention is required in respect of criminal record checks for those members of staff who have not undertaken this process with the company to ensure service users are fully protected. EVIDENCE: An adequate complaints policy is in place and the manager stated that she advises all service users and relatives that she is approachable and available should they need to address any concerns. There have been no complaints received since the last inspection. Service users spoken with expressed no concerns. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 15 An appropriate policy is in place with regards to the protection of vulnerable adults. All staff employed have appropriate criminal records checks in place, however with regards to two longer term members of staff a different company has undertaken these. All staff with the exception of two have now undertaken training in the protection of vulnerable adults. Staff spoken with were able to discuss these issues and how they would handle abuse should it occur. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26OP, 24,30YPD The quality outcome for this judgement area is adequate this judgement has been made using evidence available including a visit to the service. Service users live in a satisfactorily maintained environment however continued improvements in décor would offer a more pleasing environment. In regards to a safe environment see issues noted in standard 38. The home is clean, pleasant and hygienic. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 17 EVIDENCE: It was evident that the provider continues to work towards improving the environment. The laundry stairs have been painted with a white strip to aid distinction. The ceiling and the walls in the laundry have also been made good and easier to clean. Some service users rooms have been redecorated; however there are areas within the home, which needs further attention such as decoration in the hallways and doors, due to general wear and tear. The requirement made at the previous inspection in respect of the access to two bedrooms has been met; telescopic ramps have now been purchased. In regards to windows opening wider than regulations permit, some windows have now been fitted with restrictors. The practice in respect to the cleaning of commodes and urine bottles in the baths has ceased; bathrooms were clean and tidy on the day of the visit. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 OP, 32,34,35YPD The quality rating for this outcome area is adequate this judgement has been made using evidence available including a visit to the service. The number and skill mix of staff meets service users needs. Staff are working towards ensuring service users are in safe hands at all times. Service users may not be fully protected and supported by the homes recruitment and selection policies and procedures. Staff are working towards being trained and competent to do their jobs, however evidence that this has been undertaken is required. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 19 EVIDENCE: The duty rotas were examined and demonstrated sufficient staff are employed to meet service users needs. The manager stated that skill mix is taken into consideration when preparing the duty rota. Service users spoken with express no concerns in regards to the availability of staff. One staff member spoken with stated that due to sickness on occasion they are short staffed, however acknowledged that attempts are taken to cover shifts if this occurs. The manager and provider have discussed the night staff arrangements and the dependency of service users, there are no plans in place to increase staffing levels at night at present due to the occupancy levels. Three members of staff have attained the national vocational qualification level 2 and 2 are working towards to qualification. One member of staff is working towards level 3. The manager is currently looking into funding to commence further members of staff on this qualification. The induction programme at present is brief and the manager stated she is aiming to develop this further. One member of staff spoken with stated that they had an induction when they commenced employment, however felt that this could be improved upon. Four staff personnel files were observed only one file contained two references, the remaining having only one. All except one had current criminal record bureau checks in place, whereas a different company had undertaken this. There were no records of induction taking place. Two staff files showed evidence that supervision sessions take place. One file contained no form of identification. The manager stated that staff are working towards completing mandatory training, there was evidence to demonstrate that further course have been booked, however with the exception of the fire certificate, no others where available, the manager stated that staff have the originals, however she is intending to photocopy these and place on staff files. Service users spoken with stated that staff were kind and caring and accommodated their needs. Staff spoken with substantiated that they felt supported in their job role and one member of staff confirmed that training had taken place. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38OP, 37,39,42YPD The quality rating for this outcome area is poor this judgement was made using evidence available including a visit to the service. Service users live in a home, which is run and managed by a person who is fit to be in charge. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 21 There was little evidence available to demonstrate that the home is run in the best interests of service users. Whilst service users personal finances are safeguarded, this may be compromised due to the systems in place. The health safety and welfare of staff and service users may be compromised due to the lack of evidence available to substantiate that appropriate checks and staff training is taking place. EVIDENCE: The manager has been in place since September 2005. She has previous managerial experience and is currently looking into commencing the registered managers award. She remains up to date by attending study days and in house training. Staff spoken with spoke highly of the manager and stated that the home is well run. The manager stated that service users have completed quality assurance questionnaires in the past and she is looking to reintroduce this practice. Several Commission for Social Care Inspection questionnaires have been forwarded to service users and relatives. The provider visits the home on a weekly basis, however does not send monthly regulation 26 notices to substantiate this to the Commission to Social Care Inspection. Three service users personal allowances were checked, two corresponded with the accounting sheet, whereas one showed a deficit of £20, the manager looked into this issue and it was stated that the service user had visited the hairdresser, however this transaction had not been documented. Receipts were in place as appropriate and two staff signed for transactions. Appropriate policies were in place with regards to service users finances and gifts to staff. The fire authority has visited the home and is due to return within the week to carry out an inspection and the manager stated that there are plans to look at improving systems in place. There were gaps in the frequency of fire alarm systems being checked, there was no evidence of emergency lights being checked. There was no evidence that staff had undertaken fire drills. There were no servicing maintenance certificates available, the manager stated these were normally kept on the premises and had been completed; therefore copies of these are required to be forwarded to the commission. There were no records of water temperatures since February 2006; the manager stated this was due to the previous maintenance man leaving and the present one starting in May of this year. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 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 X 2 X 3 3 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 2 36 X 37 X 38 1 Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 23 No 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 YA6 Regulation 13(4,c) Timescale for action Risk assessments with regards to 22/07/06 entrapment are required for all service users who have bed rails in place. Risk assessments with regards to 22/07/06 entrapment are required for all service users who have bed rails in place. To ensure service users are fully 22/07/06 protected management plans to identify how risks will be managed and reduced is required once service users have undertaken a risk assessment with regards to accidents. To ensure service users are fully protected management plans to identify how risks will be managed and reduced is required once service users have undertaken a risk assessment with regards to accidents. Service users reviews are required to be service user focussed in order to reflect service users current care and condition ensuring consistency of care. DS0000059465.V288120.R01.S.doc Requirement 2 OP7 13(4,c) 3. OP7 13(4,c) 4 YA6 13(4,c) 22/07/06 5 OP7 15(1) 22/08/06 Arden Lea Nursing Home Version 5.1 Page 24 6 YA6 15(1) 7 YA17 23(5) 8 OP15 23(5) 9 YA34 19(1) 10 OP29 19(1) 11 OP29 19(1) 12 YA34 19(1) 13 YA32 19(5,b) 14 OP30 19(5,b) Service users reviews are required to be service user focussed in order to reflect service users current care and condition ensuring consistency of care. The responsible individual is required to liaise with the environmental health officer in order to implement safer systems of working thus protecting service users. The responsible individual is required to liaise with the environmental health officer in order to implement safer systems of working thus protecting service users. All staff employed are required to have all documentation as listed in schedule 2 in place to ensure service users are further protected. All staff employed are required to have all documentation as listed in schedule 2 in place to ensure service users are further protected. All staff criminal record bureau checks are required to be undertaken by the home, to further protect service users. All staff criminal record bureau checks are required to be undertaken by the home, to further protect service users Evidence is required to demonstrate that staff have undertaken mandatory training in order to substantiate that staff are trained and competent to carry out their job role. Evidence is required to demonstrate that staff have undertaken mandatory training in order to substantiate that staff are trained and competent to DS0000059465.V288120.R01.S.doc 22/08/06 22/07/06 22/07/06 22/07/06 22/07/06 22/07/08 22/07/08 22/09/06 22/09/06 Arden Lea Nursing Home Version 5.1 Page 25 carry out their job role. 15 YA39O 24 Quality assurance systems are required to be implemented to demonstrate that the home is being run in the best interest of service users. Quality assurance systems are required to be implemented to demonstrate that the home is being run in the best interest of service users. All transactions of service users finances held in safe keeping are required to be recorded and accounted for. Evidence to demonstrate that required safety checks and maintenance has been undertaken is required to substantiate the health safety and welfare of service users and staff is protected. Evidence to demonstrate that required safety checks and maintenance has been undertaken is required to substantiate the health safety and welfare of service users and staff is protected. All service users are required to have photographic identification (with consent) in place in accordance with schedule 4 to further protect service users. All service users are required to have photographic identification (with consent) in place in accordance with schedule 4 to further protect service users Evidence of water temperature is required to demonstrate that service users are protected form the risks of scalds. Evidence of water temperature is required to demonstrate that service users are protected form the risks of scalds. DS0000059465.V288120.R01.S.doc 22/09/06 16 P33 24 22/09/06 17 OP35 13(4,c) 22/07/06 18 OP38 13(4,c) 07/07/06 19 YA42 13(4,c) 07/07/06 20 OP38 Schedule 4 17(2) 22/07/06 21 YA42 Schedule 4 17(2) 22/07/06 22 OP38 13(4,c) 22/07/06 23 YA42 13(4,c) 22/07/06 Arden Lea Nursing Home Version 5.1 Page 26 24 OP38 23 The responsible individual is required to liaise with the fire authority to ensure safe systems of work are implemented thus protecting service users and staff. The responsible individual is required to liaise with the fire authority to ensure safe systems of work are implemented thus protecting service users and staff. 22/07/06 25 YA42 23 22/07/06 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 OP9 Good Practice Recommendations It is recommended that all hand written entries on service users medication chart are signed by two members of staff to demonstrate that these have been checks and are correct thus ensuring service users are further protected. That staff continue to work towards attaining the national vocational qualification level two. It is recommended that further improvement work is undertaken in regards to the décor to provide a comfortable and pleasant environment for service users. 2 3 OP19 OP28 Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. Arden Lea Nursing Home DS0000059465.V288120.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!