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Inspection on 03/10/07 for Autumn House Nursing Home

Also see our care home review for Autumn House Nursing Home for more information

This inspection was carried out on 3rd October 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 home was clean and comfortable and there were no offensive odours. Furniture and furnishings were in good condition and bedrooms were personalised. A relative commented that, "The home was very friendly and helpful staff which in turn makes my parent feel safe and comfortable" Meals were good with choice and variety. The cook did her own baking.

What has improved since the last inspection?

Overall, the home has deteriorated. There has been a high staff turnover and relatives feel that standards have slipped. One relative commented, "When my parent first went in the atmosphere was good, friendly. In recent months I feel all this has changed with all the recent staff changes. Another relative had also mentioned this but felt that things were recovering.

What the care home could do better:

Relatives considered that the home could be improved by, "A caring leadership" and "By employing more experienced carers".Standards had fallen and basic care needs were not being met, therefore this needs to improve. Systems need to improve including the procedure for monitoring accidents, recording care needs, medication records, staff recruitment and training records and quality assurance monitoring systems. The home did not have a registered manager, some staff had left and some relatives had moved people out of the home. The current acting manager had no experience and there were insufficient nursing staff employed to cover all shifts resulting in agency staff being used. Therefore, the home lacked leadership and a management structure to ensure that the home was run in the best interests of people living in the home. The owner is working with the Commission for Social Inspection and Barnsley Social Services to rectify the situation and improve the service provided.

CARE HOMES FOR OLDER PEOPLE Autumn House Nursing Home 2 Station Road Worsbrough Dale Barnsley South Yorkshire S70 4SY Lead Inspector Christine Rolt Key Unannounced Inspection 3rd October 2007 09:00 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 Autumn House Nursing Home DS0000006470.V349705.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. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Autumn House Nursing Home Address 2 Station Road Worsbrough Dale Barnsley South Yorkshire S70 4SY 01226 243057 01226 247651 autumn.house@hotmail.co.uk 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) Mrs Nurjahan Hossain Mrs Vijay Kumari Singh Post Vacant Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 60 years and above with the exception of three persons who can be 55 years or over. Of the 35 beds registered, all can be used for personal care. Twenty of these can alternatively be used for nursing care. 11th October 2006 Date of last inspection Brief Description of the Service: Autumn House is a care home providing personal and nursing care for up to 35 older people. The home is situated in a residential area of Worsborough Dale, close to all local amenities and bus routes. Accommodation is provided over two floors served by a passenger lift and stairs. The home has 23 single and six double rooms, three of the double rooms have en-suite facilities. Communal accommodation consists of two lounges and a dining room. Sufficient bathing facilities are available, with aids and adaptations in place. A central kitchen and laundry serve the home. The home is in an elevated position in its own grounds, and is reached by a steep tree lined driveway. Car parking is available. Fees were 341.50 for residential care and 442.50 for nursing care. Hairdressing, toiletries and newspapers were not included in the weekly fee and were charged separately. This information was provided on 4th October 2007. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9.00 am to 4.20pm on 3rd October 2007. Regulation Manager Mrs. A. Lindley assisted with the inspection during the afternoon. This inspection had been brought forward because of concerns about the home. The majority of people living at the home were seen throughout the day. Three people were tracked throughout the inspection. Questionnaires were sent to six people living at the home and six relatives. Completed questionnaires were received from three relatives. During the site visit, three people who lived in the home and a visitor were asked for their comments about the service provided. Care practices were observed, a sample of records was examined, a partial inspection of the building was carried out and service provision was discussed with the acting manager. The inspector wishes to thank the acting manager, members of staff, people living at the home and relatives for their assistance and co-operation. What the service does well: What has improved since the last inspection? What they could do better: Relatives considered that the home could be improved by, “A caring leadership” and “By employing more experienced carers”. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 6 Standards had fallen and basic care needs were not being met, therefore this needs to improve. Systems need to improve including the procedure for monitoring accidents, recording care needs, medication records, staff recruitment and training records and quality assurance monitoring systems. The home did not have a registered manager, some staff had left and some relatives had moved people out of the home. The current acting manager had no experience and there were insufficient nursing staff employed to cover all shifts resulting in agency staff being used. Therefore, the home lacked leadership and a management structure to ensure that the home was run in the best interests of people living in the home. The owner is working with the Commission for Social Inspection and Barnsley Social Services to rectify the situation and improve the service provided. 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. Autumn House Nursing Home DS0000006470.V349705.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 Autumn House Nursing Home DS0000006470.V349705.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): 1, 3 and 6. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives did not have the information they needed to make an informed choice. Assessments were carried out to ensure that the home could meet people’s needs but they were not informed in writing. This home does not provide intermediate care. EVIDENCE: This home does not provide intermediate care. There was no Statement of Purpose, Service User Guide or a copy of the most recent inspection report displayed and copies of the Service User Guide were not seen in bedrooms. These documents would ensure that people living in the home, prospective residents and visitors had information about the Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 9 services provided by the home. Relatives considered that information was only available some of the time. People living at the home were assessed prior to admission to the home and copies of the assessments were seen on their files. They contained a good range of information of people’s individual needs and wishes including times they preferred to get up and go to bed (See also Section Daily Life and Social Activities). The acting manager could not confirm that people were informed in writing that the home could meet their needs and there was no correspondence on people’s files about this. This was a requirement from a previous inspection. Autumn House Nursing Home DS0000006470.V349705.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): 7, 8, 9, 10 and 11. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s day-to-day care needs were not fully met and medication procedures needed improvement, but they were treated with respect and their terminal wishes were recorded. EVIDENCE: Relatives considered that people’s needs were only met some of the time and more could be done. Their comments were, “My mother needs help with food and drink, when we aren’t there we don’t know if she is getting anything. We have called many times when a cup of tea is left to go cold at the side of her”, and “…After being dressed in a morning, she is wheeled into the lounge, and that is where she stays until bedtime. The carers could be a lot more chatty to her, as she understands everything you say to her”. Relatives felt that they were usually informed of important issues but one relative felt that they “Could be more informed”. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 11 People seen and spoken to on the day were clean and tidy with clean hair and most had clean nails. Only one person was noted to have dirty fingernails to one hand. When asked about hand and nail care, she said that a particular member of staff used to look after her nails but she had since left and no-one was doing this now. Two of three people spoken to during the site visit said that staff did not always respond to buzzer when they needed to go to toilet. The files for three people were checked. These provided detailed information of residents’ individual care needs and risk assessments to ensure that residents were protected. However, the daily records did not contain sufficient information to verify that all needs were being met. Health needs were recorded in detail but personal care needs stated, “all care needs met” without specifying any particular needs that had been met and as a result, some needs were not being met. On two of the three files checked the people were not being bathed or weighed on a regular basis. According to the Bathing/Weighing Chart, one person’s most recent bath or shower was a month prior to this site visit, and both these people usually had only one or two baths or showers a month according to the records. One had not had a bath at all in May 2007 and the other had not had a bath at all in August 2007. One of these two people had been weighed only once since February 2007. The acting manager had recently introduced a bath book to enable her to monitor bathing routines and ensure that no one was missed. Social needs and leisure preferences were listed on the care plans but there was no information in the daily records of whether these were being met or any information of how people were stimulated and motivated. On the files seen there were no inventories of residents personal possessions. This was required at the previous inspection. Files contained nutritional risk assessments but did not contain the Malnutrition Universal Screening Tool. This is recommended. One person was diabetic. In the person’s file there was monitoring of this between December 2006 and July 2007 and then no further information. This was queried with the acting manager who said that these records were now kept separately. These records showed that the majority of entries were on a daily basis before breakfast but there were gaps, sometimes up to five days, and the times were not always recorded. There was no information of the normal range for this person or at what stage medical intervention should be sought. The acting manager was advised to provide clear instructions of the frequency and time that monitoring should take place and also at what stage medical intervention should be sought. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 12 Accidents and falls were recorded in the Accident Book but the perforated sheets were not removed from the Accident Book to comply with data protection. It was recommended that these forms be placed on people’s individual files, which would ensure that staff were aware of any accidents or falls. The daily records did not provide information to suggest that people who had had accidents or falls were being monitored to ensure that no injuries had been sustained. There were no specific monitoring forms seen on files and the acting manager was advised to implement this procedure as a sign of good practice. On one file a member of staff, in good faith, had marked up a sheet of paper as a 72-hour monitoring sheet for a person who had fallen. However, there was no information on this monitoring sheet to inform about the fall. As a result, staff were entering day-to-day information that would have been recorded on the normal daily records. Visits by health professionals were recorded but in one person’s file there were two forms of ‘Record of Professional Visits’ in different parts of the file. Both forms had recent entries but on different dates. The need to collate this information to ensure that important information was not missed was discussed with the acting manager. Care plans and risk assessments were reviewed monthly but were not necessarily reviewed earlier than this, e.g. following an accident, where the care plan might need to be altered to ensure the person’s needs were being met. When care plans were reviewed, there was no information of whether people living at the home or their representatives had been consulted. This was a requirement at a previous inspection. Medication was stored safely. Medication that required refrigeration was kept in a medication refrigerator and the temperature was monitored and recorded. Controlled medication was stored correctly and the Controlled Drugs Register was completed correctly. Most Medication Administration Records (MAR) sheets had photos and allergies were noted. The medication for three people was checked against their MAR sheets. Handwritten entries were not countersigned; countersigning is good practice, which reduces the risk of error. In one case a handwritten entry was not signed or dated. There were gaps in the recording on two of the three MAR sheets that were checked. A course of medication prescribed for one person was checked against the records and did not tally. An analgesic prescribed for one person had been refused for four weeks but this had not prompted staff to consider whether this medication was needed and arrange a medication review. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 13 Food supplements were entered on the MAR sheets but there was no record of whether these had been given or refused. This was a requirement at a previous inspection. One medication, Lactulose, was not always required at the prescribed times but the person asked for it at other times during the day. The acting manager was advised to discuss changing the prescription from designated times to ‘as and when required’ to fit in with the person’s routines and needs. The regular auditing of medication to reduce errors was discussed with the acting manager. Terminal care wishes were recorded on people’s files. People who lived in the home were treated with dignity. They and a relative spoke positively about the staff and the care given. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle within the home did not match people’s expectations and preferences. Personal choice and control were not always promoted. Visitors were welcome and meals were good quality with variety and choice. EVIDENCE: The home did not have a programme to inform people of any group activities. Information in the Annual Quality Assurance Assessment stated that activities took place every afternoon from 1.30 to 4.00. On the day of the site visit, two relatives had organised a game of bingo and staff were enabling people to participate. However, by 2.30 pm this group activity had finished. People’s individual social needs and preferences were written into the care plans but throughout the day, nobody was pursuing any individual activity. (See also section Health & Personal Care above). Two people who were spoken to during the site visit said they would like to go out more and another said that promises had been made about going out but they had never materialised. Relatives felt that the home could improve by providing more activities and Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 15 entertainment. Their comments were, “We do feel more could be done to involve the residents in activities more”, “There is no entertainment at all in Autumn House. The residents just sit all day long (every day) looking at each other. Nothing at all to take their mind of where they are”, and “More entertainment for residents” People said that they could go to their rooms when they wanted. Two people mentioned about going to bed at 6.00pm. When asked if this was their choice, one said that if she didn’t go then, it could be nearly 10.00 pm before staff got round to helping her to bed and this was too late. The acting manager was asked about this and she admitted that some staff complained if there were too many people still up in the evening. The acting manager was told that she needed to impress on staff that the home was run for the benefit of people living in the home and not for the benefit of staff. People living at the home said that the meals were good and there were plentiful supplies. Choices were offered at all meals and a menu board informed of the meals on offer. The lunch meal was sampled and the food was good. The cook did her own baking and was complimented on this. Specialist diets were catered for. The cook said that they had sufficient supplies of foodstuffs and there were no shortages. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Relatives and friends of people living at the home were not confident that their complaints would be dealt with appropriately. People using this service were not fully protected from abuse. EVIDENCE: The complaints procedure was displayed in the main entrance. This needed slight amendment to include timescales for action. Relatives said that they knew how to complain but they had not always received an appropriate response to their complaint. Over the last few months, relatives have expressed their concerns about falling standards within the home. As a result several people have moved to other homes. The complaints book gave brief information of complaints but there were no details of the action taken or how decisions had been reached. No other paperwork could be found. The acting manager confirmed that all staff had received training in adult protection. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 17 At the time of this site visit an adult protection case was ongoing. The local authority and the Primary Care Trust were carrying our full care reviews of all the people living in the home. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was clean, pleasant and hygienic. Most parts of the home were well maintained. EVIDENCE: People living at the home considered that the home was fresh and clean. There were no offensive odours. A relative said that there had been a shortage of cleaning staff but the home had picked up. The acting manager confirmed this. Bedrooms had been personalised by their occupants, they were clean and furniture and furnishings were in a good state of repair. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 19 Some parts of the home were in need of redecoration. The acting manager said that there was a rolling programme of redecoration. Aids and adaptations were available throughout the home. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels generally met people’s needs. People were not supported and protected by the homes recruitment procedures and staff’s skills and competence could not be assessed because of lack of documentation. EVIDENCE: A relative said that in her opinion the home had been understaffed in the recent past with only two staff on duty for almost thirty residents. She added that staffing levels had improved recently, staff were more relaxed and, “They seem to have more time for the residents and have a laugh, which they didn’t do before”. At the time of this site visit, there were four staff on duty to meet the needs of sixteen people. Prior to the inspection, staffing rotas were checked. These showed that insufficient nursing staff were employed and a predominance of agency nurses were being used to meet people’s nursing needs. In some cases agency staff were on consecutive shifts, which did not provide consistency of care for people living in the home. This was discussed with the owner who voluntarily agreed to stop admissions of nursing clients until the home had employed more nursing staff. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 21 The recruitment files were requested for five members of staff. One member of staff left in September and his file could not be found. This raised the question of whether this employee had undergone checks to determine his suitability. Another file contained no information except a selection of forms that had not been completed, signed or dated. There was no application form, no references, no date of employment, no Criminal Records Bureau disclosure, no identity documentation and no information of induction, supervision or training. An immediate requirement was issued and the acting manager was informed that this employee must not work until relevant and satisfactory documentation was available. On the three remaining files that were checked, only one had a complete application form. There was no information about induction training, supervision or training on these files. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was not run and managed in the best interests of people living at the home. Their health, safety and welfare were generally promoted and their financial interests were safeguarded. EVIDENCE: This home has not had a registered manager for almost two years. This was a requirement at a previous inspection. At the time of the site visit, the acting manager had been in this post for only one month. She had been qualified as an RGN for only one year and realised that she did not have the experience of Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 23 managing a care home. The owner agreed to employ a person with the relevant experience. The Annual Quality Assurance Assessment gave information that questionnaires were sent out and meetings were held to ensure that the home was running in the best interest of people living there. However, during the site visit, no documentation was produced as proof of these activities. Written reports of visits by the registered provider were not available. There was no quality assurance system in operation. The CSCI had spoken to the owner regarding the service provided and he had agreed to visit and/or telephone on a daily basis and take action to address the areas of concern. The owner had also attended the adult safeguarding multi-agency meeting. A sample of monies that was looked after on behalf of people living at the home was checked. Records were kept and money tallied with the records. Advice was given on numbering receipts to cross reference with the records. Some certificates and receipts were found as verification that training had been undertaken for moving and handling, food safety and infection control. However the system needs improving to ensure that records are kept of staff’s individual training needs. There were certificates available as evidence that systems within the home were serviced and maintained. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 Q DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 2 Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement Residents must be informed in writing that the home can meet their needs in respect of their health and welfare. Previous timescale 2.4.07 not met. Daily recordings must provide: • More specific information of which physical care needs have been met to ensure that no needs are missed e.g. bathing and weighing, • Information of how people’s social needs were met. An up to date inventory of each person’s personal furniture, equipment and other belongings must be recorded on their personal file. Previous timescale of 2.4.07 not met. Care plans and risk assessments must be reviewed at least once a month or sooner if considered necessary i.e. following an DS0000006470.V349705.R01.S.doc Timescale for action 28/11/07 2 OP7 12 31/10/07 3 OP7 17 28/11/07 4 OP7 15 31/10/07 Autumn House Nursing Home Version 5.2 Page 26 incident or accident to ensure that the plan of care is relevant to the person’s needs. The person or their representative must be consulted about the reviews. Previous timescale 2.4.07 not met. Remove accident forms from the accident book to comply with data protection and improve accident procedure to ensure people’s health needs are met Handwritten entries on Medication Administration Record charts must be signed and dated To demonstrate that people are receiving the medication as prescribed, administration of medication must be recorded each time on the Medication Administration Record (MAR) chart. MAR charts must be completed for all prescribed products, including food supplements, to establish whether given to resident and also facilitate stock control. Previous timescale 2.4.07 not met. People living at the home must be consulted about group and individual activities to promote motivation and stimulation. Where people’s social needs are known and recorded, action must be taken to ensure that they are given the opportunities to participate in their chosen pursuits. People must be encouraged to make own choices e.g. bedtime, so that the home is run in their best interests and not the interests of staff. The recording of complaints DS0000006470.V349705.R01.S.doc 5 OP8 13 28/11/07 6 7 OP9 OP9 13 13 31/10/07 31/10/07 8 OP9 13 31/10/07 9 OP12 16 28/11/07 10 OP14 12 31/10/07 11 OP16 22 31/10/07 Page 27 Autumn House Nursing Home Version 5.2 12 OP29 19 13 OP29 19 14 OP31 8 14 OP33 24 16 OP33 26 must provide better detail to include what action was taken and whether the complainant was satisfied with the outcome. Robust recruitment procedures must be implemented and records kept for all prospective employees to ensure that people living in the home are not put at risk (re missing file). The identified employee must not work until the relevant and satisfactory documentation has been produced to verify that people living in the home are not at risk. Immediate requirement Application must be made to the Commission for Social Care Inspection for a suitably qualified and competent person to be registered as the manager. Previous timescale of 2.4.07 not met. The service provided for persons living at the home must be evaluated by the provision and maintenance of a quality assurance system. This must take into account the views of people living in the home and other interested parties. The registered provider or his representative must visit the home each month and produce a written report of his findings. A copy of each report must be forwarded to the Commission for Social Care Inspection for perusal. 31/10/07 03/10/07 04/01/08 28/11/07 28/11/07 Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 OP1 2 3 4 5 6 7 8 9 10 11 OP38 OP12 OP16 OP19 OP35 OP7 OP8 OP8 OP8 OP9 Refer to Standard Good Practice Recommendations Display the Statement of Purpose, Service User Guide and the latest inspection report and issue copies of the Service User Guide to persons living in the home so that all interested parties have the information they need. Carry out audits of people’s files to ensure all relevant documentation is included and that no document has been duplicated e.g. Record of Professional Visits. Provide more detailed instructions for blood monitoring charts for people with diabetes. Consider implementing 72 Hour monitoring sheet following accidents to ensure that any injuries not apparent at the time of the accident are quickly noted and action taken. The provision and implementation of the Malnutrition Universal Screening Tool would highlight people at risk. The countersigning of handwritten entries on MAR charts verifies that the correct information has been written/copied An activities programme would inform people living at the home of the activities on offer Amend the Complaints Procedure to include timescales Continue with the rolling programme of redecoration The numbering of receipts would aid cross-referencing with people’s finance records. Improve the recording system of staff training to ensure staff’s individual training needs are highlighted, particularly mandatory health and safety training. Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Autumn House Nursing Home DS0000006470.V349705.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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