Inspection on 22/11/06 for Balmoral Nursing Home

This inspection was carried out on 22nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Balmoral Nursing Home 04/10/07

Balmoral Nursing Home 13/03/06

Balmoral Nursing Home 14/07/05

Balmoral Nursing Home 01/12/04

Balmoral Nursing Home 24/08/04

Balmoral Nursing Home 10/02/04

Similar services:

Ruskin Lodge

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Cornmill Nursing Home

Vitalise Sandpipers Centre

Sue Ryder Care Birchley Hall

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

CARE HOMES FOR OLDER PEOPLE Balmoral Nursing Home 29 Old Road Mottram Hyde Tameside SK14 6LW Lead Inspector Sandra Buckley Unannounced Inspection 9.30 22 November 2006 nd 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 DS0000025428.V304724.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 DS0000025428.V304724.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Balmoral Nursing Home Address 29 Old Road Mottram Hyde Tameside SK14 6LW 01457 765879 01457 765879 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 Robert Lambert Mrs Brenda Lambert Mrs Avril Marie Hunt Care Home 31 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (10), Physical disability (31), Physical disability of places over 65 years of age (31) Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No service user may be admitted into the establishment who is under 55 years of age. Maximum number of service users requiring nursing care must not exceed 31. A maximum of 2 Registered Nurses must be on duty between 7.30 a.m. and 12.30 p.m. Mon - Fri. A minimum of 1 Registered Nurse must be on duty at all other times. Date of last inspection 13th March 2006 Brief Description of the Service: Balmoral is a large detached house, located in the Mottram area of Tameside in a semi-rural setting. The home is registered to provide both nursing and residential care. Accommodation is provided in 31 single rooms, 21 of which have en-suite facilities. A separate dining room and lounge areas are available to service users on the ground and first floors of the home. The home has recently completed an extension to increase the number of single rooms and en-suite facilities. Pleasant garden areas are provided to the front of the home. The rear of the property has a secure enclosed patio leading from the main lounge which is accessible to service users. The home provides adequate toilet and bathing facilities with appropriate aids and adaptations to meet the assessed needs of the service users. The manager makes available to prospective residents the service use guide and statement of purpose. A copy of which will be displayed in the home. The range of monthly fees charged by the home was £323. 66 to £440.75. There is also a top up fee charged from £5 to £25 on certain bedrooms in the home. This aspect is discussed with the manager at the time of the resident’s admission. Additional fess charged are for hairdressing, podiatry, personal newspapers and some entertainment and trips out in the community. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection, which included an unannounced visit to the home, took place by one inspector on the 22nd November 2006. Time was spent talking to residents individually and in groups. Three staff , two relatives and the manager were also spoken to. The inspector also took a random tour of the building and looked at a selection of residents and staff records as well as other documentation including duty rotas, medication records and staff recruitment. What the service does well: What has improved since the last inspection? What they could do better: Although the home undertakes an assessment of residents needs prior to their admission more in-depth information on this assessment would be beneficial. If the exact needs of residents were undetermined an additional professional assessment should be obtained. Health and safety in the home needs to be closely monitored and the appropriate equipment purchased in line with the residents needs (sit on scales). Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 6 Some aspects of the environment required attention especially in relation to broken chairs and raised floor covering. This issue had also been brought to the attention of the owners and manager on a previous inspection and should be addressed. Staffing levels and the deployment of care and domestic staff routines in the home need to be reviewed to ensure positive outcomes for residents are maintained. This was especially noticeable during meal times when the dining experience of residents could be much improved with more staff on duty. There were many instances during the inspection were the recording system in the home needed to be improved especially in relation to care planning, accident recording and staff recruitment. In order to do this the manager needs additional supernumerary hours which would enable her to do these things. The outcomes for residents remained positive, however it was observed throughout the day that staff were rushed to complete tasks. Unless the issues identified are addressed the positive outcomes for residents may not be sustained. 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 DS0000025428.V304724.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 Balmoral Nursing Home DS0000025428.V304724.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 The quality outcome in this area is adequate. This judgement has been made using available evidence and including a visit to the service. Residents are informed of services and facilities in the home on which to make an informed choice. Assessments are undertaken prior to admission providing the home with some information about residents needs, however a more detailed assessment of residents needs would ensure that home was more confident in knowing that they could meet such needs. The home does not provide intermediate care. EVIDENCE: The homes inspection report and advice on how to contact advocacy services is displayed in the entrance hallway. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 9 The manager said the service users guide and statement of purpose was not on display because this was under review and that residents would be provided with a copy on completion. The inspector interviewed one resident who had been recently admitted into the home that said, “the manager sat with me and the family and went through all the information about the home.” The resident also said that their family had visited the home because of its good reputation in the area. Examination of residents files showed that an assessment of need had been completed. However the home’s assessment would benefit form more in depth information on the presenting needs of residents. In some instances there were queries on the diagnosis and needs of the residents, which would have benefited from additional professional information. The inspector acknowledges that outcomes for residents on this inspection were not affected, however this may not be sustained unless a review of the assessment information is undertaken. This had been recognised by the manager who had started to review the recording system. The manager said she had insufficient office time allocated for the task involved. Balmoral Nursing Home DS0000025428.V304724.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. This judgment has been used using available evidence including and a visit to the service. In the main, the health and personal care needs of residents are met. EVIDENCE: On entering the home twelve residents were still in the dining room having breakfast. Nine were in wheelchairs, five of which were without footplates posing a risk in moving and handling residents. Staff also said they did not have time to transfer residents from wheelchairs to dining chairs, thus they are not able to give pressure relief from time in wheelchairs, nor make the dining experience more normal for residents. Four residents files were looked at in depth, these provided evidence that residents had, access to health care professionals e.g. language specialist, dietician, memory clinics, and dementia care team. Where specialist measures for feeding residents were needed detailed instructions for staff were on their files. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 11 During interviews with staff they said they had received training in the care of residents who needed specialist feeding. Reviews of the care plans had taken place. The inspector noted that in one instance a record showed a significant weight loss with no further weights being recorded for the following three weeks. Staff reported that the home’s scales were sometimes faulty and for those residents who could not weight bear or sit long enough it was difficult to carry out the task. The manager said that this had been discussed and it was hoped that alternative weighing machines would be purchased. This matter needs immediate attention so as not to pose a risk to residents. Food charts of residents with additional nutritional needs had been maintained. Examination of the accident book found twelve recorded, six of which had occurred on night duty, three without specific times and three on days. The manager undertakes an analysis of accidents however the outcomes or action taken were not recorded. The inspectors followed one accident through to daily notes and care planning and found that the initial fall had been recorded unfortunately no further recordings or care planning had taken place in order to identify any progress in the resident’s condition. Evidence was on file of residents being admitted to the home from hospital on specific treatments with the home identifying that this was not in the resident’s best interests. Discussions had taken place with health care professionals in order to change treatment, which had resulted in a marked improvement in the resident’s health. Social care needs of residents were not recorded in care planning. Residents were happy with the care they received and said “ I am very happy staff treat me has they would wish to be treated” and “Staff maintain our privacy in personal care”. One relative said, “staff are always attentive to residents needs and mum always looks well cared for.” Medication is securely and appropriately stored with medication records including controlled drugs being recorded appropriately. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The quality outcome in this area is good. This judgement has been made using available evidence and a visit to the service. Routines and preferences of residents are adhered to providing residents with choice and control over their lives. Relatives and visitors are made welcome when they visit the home thereby ensuring that positive relationships are formed and continue for residents whilst living at the home. EVIDENCE: There was evidence on resident’s files that they had been informed of church services in the home. Throughout the day of inspection a number of relatives were visiting with the inspector having the opportunity to speak to two of them, both were complimentary on the manner in which staff interacted with residents. They also said hospitality was offered to them. Residents said that occasionally they have professional entertainment in the home. Christmas activities were displayed on the notice board and a trip to a Daniel O Donnell concert planned. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 13 Residents said “Staff have a bit of fun with us”, another said, “The manager comes in sometimes to do a sing-along and quiz”. There was evidence that routines in the home were flexible, one resident said I prefer to get up at eight o’clock, staff help us to get up at our leisure”. One resident had request a bottle of whiskey and staff were informing them of the best place to buy for good value. Another resident discussed their access to a talking library and how this maintains their lifestyle. All residents spoke of the good standard of food served in the home and there was always a choice. One resident said “ I don’t like two cooked meals a day so I can have a sandwich if I want”. Another said “I have my fed up days but I quite like it here.” The inspector noted that staff went to each resident asking their choice of the day’s meals. A roast chicken dinner was served at midday and a choice of bacon, egg, tomatoes or sandwiches for tea. Residents also confirmed they received a supper before retiring to bed. The inspector dined with residents at teatime and found the dining experience for residents could be much improved. There were no table’s set; staff were giving residents knives and forks out of a jug. No condiments or serviettes were on the table and residents were offered bread and butter form a large plate, which was placed on their meal plate. Staff came round and served tea from a large pot. Some residents would have benefited form individual teapots and their own plate of bread and butter. A number of residents said they did not mind this however the home should promote better standards for residents. Residents were asked if they wanted any more food. At interview staff and the manager said they had to prioritise duties because of time limits. Staff spoken with said they did not feel there was enough time to carry out the nicer aspect of their duties. The inspector noted throughout the inspection day that staff were rushed to complete their duties and attend to residents needs. Both lounges in the home have chairs placed around the walls with a small TV screen at the far end of the room, which was difficult to see. This was also difficult for residents who were sat around the sides of the room. Once again residents said they did not mind this. The home has a responsibility to ensure residents have an informed choice and viewing and hearing their favourite programmes is promoted. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,19. The quality outcome in this area is good. This judgement has been made using available evidence including a visit to the service. Residents and relatives felt comfortable in raising any concerns they may have which means that they are listened to, and responded to. Staff training in the protection of vulnerable adults ensured residents are protected from abuse. EVIDENCE: The home’s complaint procedure is situated in the entrance hallway and included in the service users guide. One relative commented that they would feel comfortable in making a complaint if there was a need. They also commented that the complaint procedure was brought to their attention during a review of care when they were asked if they had any complaints. Residents also said they would feel comfortable in complaining. One gave an example of clothes missing from the laundry and said, “the manager explained that there had been a mix up because the usual laundry person had been on holiday and that a search had begun to find the clothes, staff are very good like that”. The home maintains a record of complaints received which also included the above complaint. The Commission of Social Care had received no complaints. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 15 Staff at interview demonstrated an awareness of how adult abuse may present and what their responsibility would be if they witnessed such an event. Training had been provided in the prevention of adult abuse. Balmoral Nursing Home DS0000025428.V304724.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): 19,23,24,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. In the main the home provides a reasonable standard of accommodation and hygiene for residents, however certain areas require attention to ensure the continued safety and comfort of residents. EVIDENCE: A tour of the premises was undertaken were it was noted that four bedrooms had been refurbished and had replacement carpets. Unfortunately, this had resulted in two-bedroom doors not closing efficiently. These doors were fire doors and failure to close may pose a fire risk to residents. The manager said they would ask the homes handyman to attend to this. Six radiators were without covers the manger said these had been taken off for redecoration. These need to be replaced for the protection of residents. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 17 Floor covering in bathrooms and toilets were stained or raised from the floor. This aspect had been recorded on the home’s refurbishment plan for replacement and had been made a recommendation in two previous inspection reports. No date was given has to when these would be replaced. Several chairs were very stained; two recliner chairs were broken and posed a risk to residents. The manger said three chairs had been replaced since the last inspection. On the whole the home was clean, tidy and without odour but more heavy duty cleaning was lacking like the previous example of cleaning chairs and corridor carpets on a regular basis. The manager said this had been due to a shortage of domestic staff. Staff had now been recruited and therefore such cleaning should be in place. A new washing machine and dryer had been brought for the laundry room. Resident’s bedrooms were comfortable and personalised; many chose to stay within their rooms throughout the day. The rooms in the new extension provided a high standard of comfort and style. Balmoral Nursing Home DS0000025428.V304724.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): 27,28,29,30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. The arrangements in place to ensure that only staff who were suitable where employed at the home were inadequate which potentially posed a risk to resident’s users. Staff were trained and competent to do their jobs, however without a review of staffing levels and their deployment positive outcomes for residents may not be maintained. EVIDENCE: Examination of the homes duty rota showed agency staff was used on a regular basis. Over a period of three weeks, twelve agency staff were used to cover thirty-one shifts. Residents said, “ Staff are respectful, unfortunately there are agency staff who do not know us to well but we manage.” Interviews with staff found that they were given handovers before start of shift but agency staff were sometimes unsure of routines in the home. Written information on routines and what is expected of staff should be made available to them. Care plans of residents were available to read, however all staff said they did not always have time to read this information. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 19 Over half of the staff in the home had achieved NVQ or above. During staff interviews they gave examples of additional training which, included, moving and handling, falls prevention, dementia awareness, food hygiene and first aid also recognising depression. As mentioned previously a number of chairs in the home were dirty and badly stained which the manager said was a result of a shortfall in domestic hours. However, someone has now been recruited to the post. Information should be made available to new staff on the cleaning routines in the home. Over a weekend period there is only one ancillary staff on duty between 8am and 2pm. They are responsible for the cleaning and the in the 31 bedded home. Care staff are expected to undertake domestic duties if needed. At the time of this inspection dependency levels in the home were high. Throughout the day staff were observed to be busy attending to the needs of residents’ physical needs giving the home a rushed atmosphere. The inspector noted that whilst attending to residents staff made every effort to have good interactions with them. One resident said “staff are very good and have a bit of fun with us but they are always busy.” Whilst this did not seem to have a negative impact on residents (on this inspection) review of staffing levels and their deployment in line with the needs of residents should take place in order to maintain positives outcomes. Examination of staff recruitment records found them to be disorganised and in different formats. Application forms had not been completed fully and in some instances not dated. Only one reference had been obtained for a member of staff, which had not been signed or dated. It was difficult to assess the actual start date of applicants because these had not been recorded in order to confirm that criminal record bureau checks had been applied for before commencement of employment. In another instance two references had been received which did not have a date on and had not been dated by the home on receipt. Issues of health related problems had not been explored or recorded. The manager said these had been discussed with the applicant but there had been a failure to record the outcome due to pressure of work and the limited time allocated for administration hours. The home must ensure that recruitment records are maintained appropriately and that references which are not dated or signed are questioned (by the manager) as to there validity. It is acknowledged that on this inspection outcome for residents remained positive however the shortfalls indicated throughout this report may result in these not being maintained over a period. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 20 At interview staff demonstrated a good knowledge of residents in the care and how training had improved their understanding. The inspector had the opportunity to interview two student nurses on placement in the home who were complimentary regarding care delivery in the home. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31,33, 35,36,37,38 The quality outcome in this area is good. This judgement has been made using available evidence and a visit to the service. The manager is experienced and provides the staff group with good management. However, aspects of her management are being compromised by lack of sufficient management time which whilst not impacting on the home greatly now, may at some stage impact on the care to residents. EVIDENCE: The registered manager is a qualified registered nurse with many years experience in care. She keeps up to date with current knowledge by attending short courses in line with the residents needs. There was evidence on file that staff supervision and meetings take place. Residents meetings are held both on a formal and informal basis with residents confirming that the manager speaks to them on a daily basis. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 22 The agenda form the last residents meeting included Christmas activities, advice on the homes complaints procedure and the manager seeking feedback on a recent movement to music activity. Residents were also informed that two student nurses would be on placement in the home for a number of weeks. A number of shortfalls have already been identified in this report, mainly around record keeping. The manager has attributed much of this to having insufficient time in the office to allow her to undertake management tasks. Appropriate documentation was in place confirming that equipment and appliances were serviced and maintained as necessary. The lack of radiator covers in certain areas of the home (which had been removed when re-decoration had taken place) and wheelchairs without footplates also pose a risk to service users. Staff training in Health and Safety, falls prevention, moving and handling and first aid had taken place. Any money held on behalf of residents was securely and appropriately stored and records maintained. Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 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 3 2 X X X 3 3 X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP8 Regulation 12 Requirement Timescale for action 31/12/06 2 OP29 19 3 OP38 23(4) The registered person must ensure that the health and welfare of residents is maintained (by the provision of suitable scales and the use of footplates on wheelchairs). The registered person must 31/12/06 ensure that staff are suitably vetted prior to employment and that records support this. The registered person must 31/12/06 ensure that suitable fire safety measures are in place (Fire doors should be securely fitted to allow closure for the protection of residents). Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 25 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 OP3 OP27 Good Practice Recommendations The registered person must ensure that assessments are completed in sufficient detail to provide staff with enough information to ensure they can meet residents needs. The registered person should ensure that agency staff have sufficient information to carry out duties in the home. A review of staffing levels and deployment of staff should take to ensure staff have sufficient time to carry out their duties. The registered person should ensure that a review of domestic and cleaning routines take place providing written information for staff to follow. The registered person should ensure that the manager’s supernumerary hours are reviewed and increased to ensure sufficient time to carry out their duties. The registered person should ensure that a care plan is in place for each assessed need of residents. This plan should also reflect the social interests and activities of residents. The registered person must ensure that accident recording is reported fully, carried through to care planning and daily reports with progress of the residents being monitored through the recording systems. The registered person must ensure that a review of recording systems in the home takes place. The registered person should replace the floor covering in the bathrooms and toilets. 3 4 5 6 OP26 OP38 OP7 OP8 7 8 OP37 OP19 Balmoral Nursing Home DS0000025428.V304724.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 DS0000025428.V304724.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. 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