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Inspection on 18/08/06 for Balmoral Nursing Home

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

This inspection was carried out on 18th August 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 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

All of the comments made to the inspector were positive. Residents said the staff were `very helpful`. Relatives were happy with the care provided to their loved one and stated that they had good relationships with the staff at the home. One relative said the care provided was `very good`. The interactions observed and overheard between staff and residents appeared respectful, cheerful and caring. Another relative stated that the staff and management had been `very welcoming` and supportive. Full needs assessments were not always carried out prior to admission. The home had a complaints procedure, to ensure any complaint was taken seriously. Any complaints that had been made were handled within the 28 days timescale outlined in the complaints procedure. Clear records were kept with regard to the outcome of complaints. Staff were seen to knock on doors before entering. Residents were able to choose whether to spend time in their rooms, or in communal areas. Systems were in place to ensure the safe storage and administration of resident`s monies. Good progress was being made in relation to training. The training plan was on target. Staff said that the manager was approachable and supportive. One nurse was `very happy and satisfied` with the education and support he had received from the management.

What has improved since the last inspection?

Recruitment procedures were followed and staff files included all the necessary documents. All residents needing the use of `bed-sides` had been assessed appropriately.

What the care home could do better:

The `contract of care/statement of terms and conditions` had not yet been provided to all service users. Some files checked contained detailed needs assessments that clearly highlighted that people were suffering from differing forms of dementia. The home is not registered to care for people in this category. The organisation must apply to register this category of service user. A large number of female residents were not wearing stockings. On checking individual care plans there was no mention of people`s wishes not to wear them. People had long and dirty fingernails, which did not uphold peoples health and hygiene needs. Wheelchairs were being used without footplates and this was not referred to in the moving a handling assessments. One resident needed three (3) people to assist with his moving and handling needs. Again this was not clear in the assessments. Medication administered when required (PRN) was not recorded consistently.The routines at the home were had become inflexible. Staff did not have time to spend with residents for social interaction. Staff were not fully aware of the Adult Protection policy. A tour of the building identified that some areas of the home were in need of decoration. Some of the specialist bathing facilities were inoperable. The rota evidenced that agreed levels of staff were not being maintained. Two visitors spoken with said they were unhappy with the levels of staff. The manager should apply to register with the CSCI. Records should be organised in a way, which allows information to be easily retrieved.

CARE HOMES FOR OLDER PEOPLE Balmoral Nursing Home 6 Beighton Road Woodhouse Sheffield South Yorkshire S13 7PR Lead Inspector Mr Rob Curr Key Unannounced Inspection 18th August 2006 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 Balmoral Nursing Home DS0000021767.V312023.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. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Balmoral Nursing Home Address 6 Beighton Road Woodhouse Sheffield South Yorkshire S13 7PR 0114 254 0635 0114 254 8159 none None Four Seasons Healthcare (England) Limited (Wholly owned subsidiary of Four Seasons Health Care Ltd) Vacant Care Home 90 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) Category(ies) of Old age, not falling within any other category registration, with number (90) of places Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2006 Brief Description of the Service: Balmoral is a purpose built home, which provides nursing and personal care to older people. It is situated in the village of Woodhouse, within easy reach of shops, churches, public transport and small parks. Balmoral is a large home and accommodation is provided over three floors. There are stairs and lifts to each floor. There are TV lounges, sitting rooms and separate dining rooms were service users are able to have meals with other service users or their relatives. Chiropodist, hairdressers and various complementary therapists attend the home. Whist the majority of the service users are permanent, the home also provides short term and respite care. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Two inspectors undertook the site visit, from 8.30 am until 3.00 pm. The second inspector was Sue Turner. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, rotas, staff training and recruitment and fire records. A number of care staff and nurses were spoken to about their skills and experiences of working at the home. Discussions took place with the manager, administrator and catering staff. A number of residents were interviewed along with four relatives. The inspector would like to thank the manager and her staff team for their support to the inspection process. What the service does well: All of the comments made to the inspector were positive. Residents said the staff were ‘very helpful’. Relatives were happy with the care provided to their loved one and stated that they had good relationships with the staff at the home. One relative said the care provided was ‘very good’. The interactions observed and overheard between staff and residents appeared respectful, cheerful and caring. Another relative stated that the staff and management had been ‘very welcoming’ and supportive. Full needs assessments were not always carried out prior to admission. The home had a complaints procedure, to ensure any complaint was taken seriously. Any complaints that had been made were handled within the 28 days timescale outlined in the complaints procedure. Clear records were kept with regard to the outcome of complaints. Staff were seen to knock on doors before entering. Residents were able to choose whether to spend time in their rooms, or in communal areas. Systems were in place to ensure the safe storage and administration of resident’s monies. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 6 Good progress was being made in relation to training. The training plan was on target. Staff said that the manager was approachable and supportive. One nurse was ‘very happy and satisfied’ with the education and support he had received from the management. What has improved since the last inspection? What they could do better: The ‘contract of care/statement of terms and conditions’ had not yet been provided to all service users. Some files checked contained detailed needs assessments that clearly highlighted that people were suffering from differing forms of dementia. The home is not registered to care for people in this category. The organisation must apply to register this category of service user. A large number of female residents were not wearing stockings. On checking individual care plans there was no mention of people’s wishes not to wear them. People had long and dirty fingernails, which did not uphold peoples health and hygiene needs. Wheelchairs were being used without footplates and this was not referred to in the moving a handling assessments. One resident needed three (3) people to assist with his moving and handling needs. Again this was not clear in the assessments. Medication administered when required (PRN) was not recorded consistently. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 7 The routines at the home were had become inflexible. Staff did not have time to spend with residents for social interaction. Staff were not fully aware of the Adult Protection policy. A tour of the building identified that some areas of the home were in need of decoration. Some of the specialist bathing facilities were inoperable. The rota evidenced that agreed levels of staff were not being maintained. Two visitors spoken with said they were unhappy with the levels of staff. The manager should apply to register with the CSCI. Records should be organised in a way, which allows information to be easily retrieved. 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. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. Standard 6 does not apply to this home. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. The statement of purpose and service user guide was available. The ‘contract of care/statement of terms and conditions’ had not yet been provided to all service users. Assessments of needs were undertaken prior to admission. These assessments did not always ensure all identified needs of the prospective resident could be met. Prospective residents and/or their representatives were able to visit the home prior to admission, to inform their choices. EVIDENCE: Copies of the Statement of Purpose and Service User Guide were on display in the entrance area of the home to enable visitors to read. Along with this there were a variety of useful policies and procedures. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 10 A number resident’s file checked contained detailed needs assessments that clearly highlighted that people were suffering from differing forms of dementia. The home is not registered to care for people in this category. The organisation have made initial contact with the Commission for Social Care Inspection (CSCI) to vary the category of people that can support. This was discussed with the manager. Families had been involved in the assessment process. Prospective residents and their representatives were able to visit the home, have a look around, and meet other residents and staff before choosing to move in. Two relatives spoken with said that this was very helpful in deciding which was the right home to use. One relative stated that the staff and management had been ‘very welcoming’ and supportive, which helped in their decision. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, and 11 Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. Each resident had a plan of care, to inform staff of the actions required to meet assessed need. Further detail was required to ensure all relevant information was recorded. Records did not always evidence that residents’ health care was monitored, to maintain health. The recording and administration of medication was in the main well managed, to promote residents safety. Interactions observed between residents and staff evidenced that resident’s privacy and dignity was respected. Written policies and procedures were in place regarding dying and death, to ensure residents and their relatives were supported sensitively. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 12 EVIDENCE: Six care plans were examined. Some sections of the care plans seen were comprehensive and contained detail of the staff action required to ensure needs were met, for example, methods of communication. Other sections of the plans examined contained insufficient detail to inform staff how to respond to specific behaviour. There were a number of residents (4) being care for in their bedrooms. On meeting these residents it was observed that they had the appropriate support in terms of general health care and person hygiene. The plans contained records of health assessments, such as moving and handling and pressure sores, although one file did not contain a continence assessment. A large number of female residents were not wearing stockings. On checking individual care plans there was no mention of people’s wishes not to wear them. People had long and dirty fingernails, which did not uphold peoples health and hygiene needs. Wheelchairs were being used without footplates and this was not referred to in the moving a handling assessments. One resident needed three (3) people to assist with his moving and handling needs. Again this was not clear in the assessments. Care plans contained information on contacts with health care professionals, such as general practitioners and specialist nurses. Qualified staff administered medication. Part of a medication administration round was observed; medication appeared to be administered correctly and safely. Medication was stored securely. Medication administration records were fully completed and up to date although the medication administered when required (PRN) was not recorded consistently. The details recorded corresponded with the medication stored. Staff were observed to respect service users privacy by closing bathroom and bedroom doors. Staff were seen to knock on doors before entering. Residents were able to choose whether to spend time in their rooms, or in communal areas. Residents preferred form of address was respected. Staff were seen to treat service users respectfully. The dependency level of some of the residents prevented staff from responding promptly to residents that became anxious or required assistance. A policy and procedure were in place regarding dying and death. Relatives spoken with confirmed that they were kept informed of their loved ones health. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14 and 15 Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. Activities were provided for residents, to improve choice and quality of life. The routines at the home were had become inflexible. Staff did not have time to spend with residents for social interaction. An open visiting policy was in operation, in order to develop and maintain good relationships with resident’s representatives. Contact with relatives and friends were supported. The homes menu was varied, and special diets were catered for, to meet residents’ needs and maintain health. EVIDENCE: Staff reported that the majority of residents were unable, or chose not to, participate in some of the planned group activities. Staff also said that they do not have time to spend with residents on a social level. Choices would be improved with the introduction of additional staffing at busy times. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 14 Residents were seen to walk freely around the home. A visitor spoken with said ‘I am always made to feel welcome, and have no concerns at all about the care of my relative, I am very happy with the care provided’. Staff endeavoured to support residents choices, and were overheard to offer individuals choice of breakfast. The homes menu was varied and choices were offered. One resident spoken with said the food was ‘lovely’. Staff sat with the residents that required assistance with eating, but this support was given in public area. This does not fully uphold people’s dignity. The cook and her team were clearly aware of individual residents special dietary requirements. There were plentiful stocks of food, which staff had access to, to provide snacks and drinks during the evening and night, if required. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 16 and 18. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened and responded to. An adult protection procedure was in place. Staff were not fully aware of these procedures, to ensure residents safety was promoted. EVIDENCE: The complaints procedure was on display in the entrance area of the home. A record of complaints was kept. A number of complaints had been received since the last inspection. These had been handled well and the outcomes of these were recorded. The staff spoken with were unclear about the procedures to undertake in regard to adult protection but clear about the homes complaints procedure. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. The home was clean and generally well maintained, to provide a pleasant environment for residents. Insufficient bathing facilities were provided. Controls of infection procedures were in place, to promote resident’s health and safety. EVIDENCE: A tour of the building identified that some areas of the home were in need of decoration. Some homely touches were provided to create a comfortable environment for the residents. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 17 A handy person was employed to help maintain the environment. A rolling programme of redecoration and replacement was in place. There were plans to refurbish parts of the home. This was discussed with the manager. Some of the specialist bathing facilities were inoperable. Staff had to transport people to other parts of the home for them to bathe. This was not upholding people’s dignity. Control of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. Insufficient staff were provided to meet the needs of residents. Some staff undertook NVQ training, to enhance their skills, however, required levels of NVQ trained staff had not been achieved. The recruitment policies and procedures were followed consistently. These practices ensured that staff were suitable for the post. A range of training was provided to staff, to improve their skills and enable them to support residents effectively. EVIDENCE: The rota evidenced that agreed levels of staff were not being maintained. One resident spoken with said that there ‘were not enough staff’, ‘sometimes we have to wait ages to get up or go to bed’. Two visitors spoken with said they were unhappy with the levels of staff. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 19 The rota for the following day (Saturday) indicated that that there was only one carer and one nurse on duty in the evening. This was discussed with the manager and she took immediate action to remedy this. Care staff had achieved NVQ Level 2 or above in care and a number of care staff were due to commence the training. Good progress was being made in relation to training. The training plan was on target but the requirement to have a minimum of 50 of the staff team trained to NVQ Level 2 in Care was not quite met. Induction and ongoing training were provided to staff. Whilst relevant training events had been organised, further emphasis needs to be placed on dedicated Adult Protection training and managing challenging behaviour. This clearly did not meet the needs of residents. Every effort must be made to ensure staff attend the training organised to equip them with the skills needed to provide residents with a good quality of life. Discussions with the homes management, staff, one relative, and records examined, evidenced that some residents displayed challenging behaviour on occasions, yet only a minimum of staff had attended relevant training. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37 and 38 Quality in this outcome area was adequate. This judgement has been made using available evidence, including a visit to the home. A manager was in post but had not applied to be registered with the CSCI. A quality assurance system was in operation, to obtain and act upon the views of residents and relatives. Systems were in place to ensure resident’s monies were safely managed. Staff supervision systems required improvement, to ensure service users interests were maintained by best practice. Appropriate policies and procedures were in place. Records were stored securely to protect confidentiality. Health and safety systems were, in the main, maintained, to ensure residents were safe. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 21 EVIDENCE: A quality survey had been undertaken with residents and/or their representatives to gauge the service provided and obtain views and suggestions for improvement. The results of surveys had been collated. The surveys examined all made positive comments about the home as well as areas of improvement. Resident’s monies were stored securely. The inspector examined two finance records, the amounts kept tallied with the records held. Informal supervision took place on a daily basis. However, formal staff supervision, to support and enhance staff skills, did not take place at the required frequency. A range of policies and procedures were in place to promote good practice and ensure resident’s needs were met. In the main, records were securely stored, however, the files and documents kept in one area of the home were in poor order, making it very difficult to retrieve information. The equipment at the home was serviced and maintained. Fire records evidenced that weekly fire alarm checks took place. Fire drill training took place on a regular basis. A training matrix had been developed. This enabled the manager to arrange and provide appropriate training. A proportion of staff had undertaken training in first aid. The inspectors noted a number of incidents of ‘skin tears’ and ‘small lacerations’ to the shin area of some residents. This was discussed with the manager. The inspectors considered that some refresher training in relation to moving and handling specifically around wheelchair use, would be beneficial. The manager collated the number of accidents and incidents that have been reported. The manager needs to build in a falls management system to aid the reduction and elimination of some of these incidents. On checking the accident records, there was an incident that had not been reported to the CSCI. This incident did not appear on the managers audit system. The manager agreed to inform the CSCI retrospectively of this incident. Some of the accident reports were difficult to read due to illegible handwriting. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 2 2 Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 5 Requirement Each service user must be provided with a written contract/statement of terms and conditions with the home. (Previous timescale of, 10/1/05, 01/12/05 and 31/05/06 not met) Care plans must contain specific detail on the staff action required to ensure assessed needs are met. Continence assessments must be in place where appropriate. Resident’s wishes regarding the wearing of stockings must be clearly identified within the care plan. Attention must be paid to resident’s fingernails to keep them clean at all times. Residents must have a choice in rising and retiring times. No service user must be admitted that is outside of the registered service user category. All moving and handling assessments must be DS0000021767.V312023.R01.S.doc Timescale for action 18/10/06 2 OP7 15 18/10/06 3 4 OP7 OP7 15 15 18/10/06 18/10/06 5 6 7 8 OP7 OP14 OP4 OP33 OP7 OP38 15 12 CSA 15 18/08/06 18/10/06 18/08/06 18/10/06 Balmoral Nursing Home Version 5.2 Page 24 9 10 11 12 13 OP9 OP12 OP15 OP18 OP19 13 18 18 13 23 14 OP19 16 15 16 17 18 OP22 OP27 OP28 OP31 23 18 18 CSA comprehensive and up to date. The use of PRN medication must be recorded consistently. Deployment of staff must allow for staff to have ‘social’ time with residents. Residents that require assistance with taking a meal must be offered this in a private setting. All staff must be aware of the action required if an allegation of abuse is suspected. A programme of renewal and maintenance of the premises (with timescales) must be produced and sent to the local office of the CSCI for agreement. All areas of the home used by service users, must be well maintained and in a good state of repair. Therefore redecoration, replacement of carpets, furniture and furnishings must take place to ensure that standards are met. (Previous timescale of 10/1/05,1/12/05 and 30/06/06 not met) The identified specialist bathing facilities must be repaired or replaced Agreed staffing levels must be maintained at all times. 50 of care staff must be trained to NVQ level 2 in care. The organisation must apply to vary the category of registration to accommodate the service users suffering from various levels of dementia. Staff must receive formal supervision at eh required frequency of 6 times a year. The manager must retrospectively inform the CSCI of the identified incident. The legibility of handwriting DS0000021767.V312023.R01.S.doc 18/10/06 18/10/06 18/10/06 12/12/06 18/10/06 01/01/07 18/10/06 18/08/06 18/10/06 18/08/06 19 20 21 OP36 OP37 OP37 18 37 37 18/10/06 18/10/06 18/10/06 Page 25 Balmoral Nursing Home Version 5.2 22 23 24 OP38 OP38 OP38 OP18 23 23 19 25 OP38 19 must be monitored. Staff must have specific training in the use of wheelchairs. The management should develop a strategy to lessen the incidents of falls and accidents. Any identified gaps in training must be provided. All staff must have up-to-date training in Adult Protection and Managing Challenging Behaviour. Wheelchair footplates must be used at all times – unless specified within a comprehensive risk assessment. 18/10/06 18/10/06 12/12/06 18/08/06 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 2 Refer to Standard OP29 OP31 Good Practice Recommendations Records should be organised in a way, which allows information to be easily retrieved. The manager should apply to the CSCI for registration. Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Balmoral Nursing Home DS0000021767.V312023.R01.S.doc Version 5.2 Page 27 - 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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