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Inspection on 24/11/05 for Camberwell Green Nursing Home

Also see our care home review for Camberwell Green Nursing Home for more information

This inspection was carried out on 24th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What has improved since the last inspection?

Previous requirements that had been met by this inspection showed that the home has got better at recording medication administration, reducing noise levels in the lounge area, stopping the practice of leaving service users waiting in the hallway for long periods of time, reducing the amount of inappropriate staff information that is placed on the walls of the home and increasing the security of the building at the front of the home. There is a new manager in post now who will hopefully be able to make further improvements when he has had more time to settle into the service.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Camberwell Green Nursing Home Camberwell Green Care Centre 54 Camberwell Green Camberwell London SE5 7AS Lead Inspector Lisa Wilde Unannounced Inspection 10:00 24 & 26 November 2005 th th 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 Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 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. Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Camberwell Green Nursing Home Address Camberwell Green Care Centre 54 Camberwell Green Camberwell London SE5 7AS 020 7708 0026 020 7708 0027 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) Apta Healthcare (UK) Ltd Carol Lee Care Home 55 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. until notification is received from the Operations Director, this home will accommodate 42 service users only, aged 60 years and above (female) and 65 years and above (male) and chronic sick and disabled persons aged 40 years and above Up to six residents to be accommodated on the ground floor 2. 3. Date of last inspection 12th August 2005 Brief Description of the Service: Camberwell Green Care Centre Care Centre was operated by Ashbourne Eton Limited but has recently been taken over by Southern Cross Housing. Camberwell Green Nursing Home was able to provide care with nursing for up to 55 people up until June 2004. The home asked to reduce its numbers at that time. The home can currently accommodate a maximum of 42 service users and a condition of registration is in force which states this. The Certificate of Registration has been amended to reflect these changes. Service users may be older people or aged forty and over and require care as a result of physical disability, although at the time of this inspection and for a considerable period before it there have been no service users under the age of sixty. The home is purpose built and located in the centre of Camberwell close to public transport routes, shopping and leisure facilities. The home has four floors and there are two lifts available. Since June 2004 three floors are being used and the top floor has been closed. Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days in November 2005. The manager was present on the first day but not the second, which was at the weekend. The inspector spoke with service users, their families who were visiting during the inspection and staff after meeting with the manager and looking through record and files. The manager had only been in post for around six weeks by the time of this inspection and as such had not had a lot of time to address the issues raised in the last report. However, given the limited time he had, he had already made some improvements and talked abut plans for further action he is to take to make sure that the requirements of previous reports are to be met. Service users and their families who spoke with the inspector had generally positive views of the home saying that their relatives were always well cared for and that staff were very kind. Staff who spoke with the inspector showed a commitment to working with the service users, good knowledge of the specific needs of individuals and a desire to provide a good service. The home has suffered from the lack of permanent management for a significant period of time and the inspector looks forward to the new manager now having the opportunity to ensure that the requirements of this and previous reports are met by the next inspection and more of the National Minimum standards are achieved. What the service does well: From the standards assessed at this inspection the home showed that: • senior staff undertake an assessment of prospective service users needs and areas of risk before someone moves to the home. • service users’ healthcare needs are met • generally the home is operating the procedures for effective medication management and administration consistently • service users are supported to die in the home if they choose rather than be transferred to hospital if there is no need. • service users can maintain contact with their family and friends as they choose when they visit the home. • formal written complaints are taken seriously and fully investigated • policy and procedures are in place to protect service users from abuse • the home is safe and well maintained. • a rolling programme of core training is offered to staff which covers the basic elements of care to be provided • the home is managed by a permanent person who showed on this inspection that they fit to be in charge. Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: 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. Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 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 Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 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): 3 Generally senior staff undertake an assessment of prospective service users needs and areas of risk so that staff and the service user know that the home can meet those needs before someone moves to the home. Standard 6 does not apply as this home does not provide intermediate care. EVIDENCE: The manager said that senior staff will visit a prospective service user to make their assessment prior to them coming to the home. The files showed that Community Care Assessments are received or service users prior to them being accepted at the home but not all files had written pre-assessments by the home in place. Nursing staff said that some of the pre-assessments may have been archived for the longer term service users. Pre-assessments covered all areas of healthcare and personal care but did not assess the individuals needs around activities or other social requirements. This issue is addressed in this report under Standard 7. Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 9 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 & 11 Although there are care plans in place they do not cover all areas of service users’ individual needs and are not consistently completed. This means that the home cannot know that they are operating all established programmes of care and cannot evidence that they are meeting all service users needs. Service users’ healthcare needs are met by care or nursing staff or by bringing in other professionals. Care files show accurate records are maintained of healthcare programmes. Generally the home is operating the procedures for effective medication management and administration consistently although stock checking is not effective which means that accurate records are not maintained of all medication held in the home. The home works with service users and their families to ensure that they are supported to die in the home if they choose rather than be transferred to hospital if there is no need. Clear and comprehensive records of these palliative care plans are not held on the files to ensure that all staff are certain of action to be taken in the event of dying or death. EVIDENCE: Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 10 There was a previous requirement that the Registered Manager must ensure that all care plans are consistent, written with the involvement of the service user and reviewed monthly as required. There was evidence from the files and from talking with the manager that some work had begun in this area but not all files contained consistent information that evidenced that care plans had been written with the involvement and consent of service users and their families. The requirement is therefore repeated. (See Requirement 1) There was a previous requirement that the Registered Manager must ensure that service users are consulted about their preferred times of getting up and going to bed, that this is recorded in their care plan and that in practice this is carried out by staff. The manager said that this had occurred but none of the files examined by the inspector showed written evidence that such consultation had taken place and the requirement is repeated. (See Requirement 2) There was a previous requirement that the Registered Manager must ensure that information around service users healthcare needs is held and recorded/monitored in the care files. There was evidence in the files that healthcare needs are monitored and recorded effectively. There was a previous requirement that the Registered Manager must ensure that systems and procedures for the management, administration and recording of medication are operated consistently and effectively by all staff. The medication stocks and records were checked and found to be adequate apart from the area of stock checking where it was found that accurate records of all medication kept were not consistently being maintained. (See Requirement 3) There was a previous recommendation that the Registered Manager should ensure that care files are organised into sections to make information clearer and easier to access. Although not all files had been sorted out by the time of this inspection there was considerable evidence that most of them had been done and the rest would be done as soon as possible. Throughout the inspection staff were seen to enter service users’ rooms without knocking. This was mentioned in one service users’ last review by their family. Some staff also talked in front of service users about other service users’ healthcare or personal care needs. (See Requirement 4) The inspector talked with staff about the procedures in place for when a service user is dying and wishes to remain in the home rather than be transferred to hospital if possible. There were handwritten notes in place for one service user who has requested such measures but these were writen on he back of another note in the file and were not easy to find. Staff said that Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 11 they consult fully with the GP and relatives to ensure that all understand and agree with the procedures in place. Staff said that they are aware of the borough’s paliative care nurse and make links with her as need be. Although it appeared that work is done in this area to support service users to die in their own home, the notes of such plans need to be written in more detail and a clearer format, as part of the overall care plan. (See Requirement 5) Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 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 lifestyle of service users does not reflect their expectations and preferences and does not satisfy all of their social, cultural and recreational needs as not enough work is being done in the area of appropriate individual activities for service users. Service users can maintain contact with their family and friends as they choose when they visit the home. The home cannot show that they are providing food that is pleasing to service users as some service users and their families said they are not happy with the food provided and there is not enough choice for people from a non-British ethnic background. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that service users have access to a hairdresser in the home who can cut African and Caribbean hair. A new hairdresser who can cut all hair types has been employed. There was a previous requirement that the Registered Manager must ensure that a consultation is carried out with all service users as to what activities they would choose to engage with on a day-to-day basis. The results of this Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 13 survey must then lead to an individual programme of activities support being drawn up in the care plan and offered to each service user. The activities coordinator has completed the same activities care plan for some service users which was seen on file but the required consultation has not been carried out and individual, personalised activity assessments and programmes are not in place. (See Requirement 6) The current activities co-ordinator has expressed a wish to move over to the care side of the work at the home so the home will be without an activities co-ordinator soon. During the inspection, nursing and care staff did not appear to have enough time to spend with service users doing anything other than personal or healthcare activity althoughthere appeared to be more time on the second day of the inspection which was a Saturday.This area of work at the home is in need of considerable input to make sure service users are being appropriately stimulated and engaged. Visitors to the home said that they are allowed to visit whenever they choose but that if their relative wants to go out into the local community they have to taek them as there is not usually any staff to do this in an unplanned way. This appears to be another issue linked to the staffing levels addressed in this report under Standard 28. There was a previous requirement that the Registered Manager must ensure that service users are not left in the entrance hall for significant periods of time while they are waiting for their ambulance escort. The manager said that this had been reviewed and service users are not brought down to the ground floor until the ambulance is due and if they do have to wait, they wait in the lounge. Over the two days of the inspection, no service users were seen to be waiting in the hallway. There was a previous requirement that the Registered Manager must ensure that a consultation takes place around the issue of food at the home, that includes reference to cultural, ethnic and other preferences and that the results of this consultation are acted upon. This consultation has not as yet taken place and the requirement is repeated. (See Requirement 7) Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 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 & 18 Formal written complaints are taken seriously and fully investigated. Records are not maintained of day-to-day complaints and concerns which means that patterns of concern cannot be tracked and comprehensive action cannot be taken to address ongoing issues. Policy and procedures are in place to protect service users from abuse but staff are not fully trained in or aware of the issues of vulnerable adults which means that service users may be being put at some risk. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the Complaints Procedure includes the new name of the Commission and makes reference to who they are and why someone may want to complain to them. This had not been done but the manager did this by the week following the inspection and sent it through to the inspector. The home records formal written complaints but does not keep a record of day-to-day issues and concerns raised by service users and their families. This means that patterns of concerns cannot be audited and nor record of any action taken is taken. (See Requirement 8) The manager found the organisation’s protection of vulnerable adults policy and Southwark’s vulnerable adults procedure at the organisation’s other home around the corner to this home. Training records showed that staff have not received training and adult protection. (See Requirement 9) Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 15 Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 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, 25 & 26 Generally the home is safe and well maintained. Toilets and shower/rooms in the home are decorated in an institutional manner and not suitable for service users’ needs. Specialist equipment in use in the home has not been assessed by an occupational therapist which means that service users may not be using the safest most effective equipment to meet their needs. EVIDENCE: There was a previous requirement that the Registered Manager must investigate alternate systems such as loop systems for the hard of hearing to listen to TVs in communal areas so that the practice of having the TV volume on loud and on different channels in the same room can stop. The TVs were playing appropriately during the inspection and the manager said that he had had a meeting with someone to investigate alternate systems and they now use subtitles on the TV. Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 17 There was a previous requirement that the Registered Manager must arrange for service users to be provided with keys to their rooms unless their risk assessment suggests otherwise. The manager said that service users generally did not want keys to the front door and could not use them if they did. A discussion was held about the ethos issues and message behind providing or offering someone a key to their home. No risk assessments or statements were on file to explain that someone had chosen not to have a key or they were deemed at too great a risk to be given a key. (See Requirement 10) There was a previous requirement that the Registered Individuals must ensure that the planned development of the front garden area is carried out as priority to ensure the safety of service users and security of the building when the front doors are open. There has been some lightweight fencing put up but when the lounge doors are open in the summer (as at the previous inspection) this fencing would not be secure enough to stop anyone entering the lounge if they chose to. Given the season the doors are not beng opened but the manager was asked to assure that this situation would be reviewed when the warmer weather meant that service users wanted the doors kept open. There was a previous requirement that the Registered Manager must ensure that work is carried out on all the toilets and shower/bathrooms to decorate them in a manner that is non-institutional, chosen by the service users and as homely as possible given the equipment that may need to be kept in some of them. Some work has been done in some bathrooms but on the whole they are still as before and the requirement is repeated. (See Requirement 11) There was a previous requirement that the Registered Individuals must ensure that an occupational therapists assessment of the building and all equipment and adaptations within it is carried out to ensure that service users are safe and receiving the most appropriate specialist support. Any recommmendations made in the report must be addressed. The manager felt that certain checks had taken place on some equipment and facilities when the building was developed but could not as yet find the evidence. The requirement is therefore repeated and slightly reworded. (See Requirement 12) There was a previous requirement that the Registered Manager must ensure that notices to staff and other posters are not placed on the walls of the home unless they are absolutely necessary and that any information placed on walls is physically accessible to service users. This had occurred. There was a previous requirement that the Registered Manager must ensure that the home is free from offensive odours at all times. On the first day of the inspection the building was free from odours. On the second day the second floor smelt of urine although cleaning of some rooms was taking place. This issue will be assessed again at the next inspection. Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 18 There was a previous recommendation that the Registered Provider should seek an alternative location for the photocopying machine. This has now been moved out of the communal area and into the staff office. Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 home cannot show that all service users’ needs are being fully met by a sufficient number of staff. A rolling programme of core training is offered to staff which covers the basic elements of care to be provided. More specific areas of training such as care planning and End of Life Care is not provided as yet. Induction and Foundation programmes that meet the required standards for Skills For Care (previously TOPSS) are not in place which means that staff are not receiving a fully induction into the care to be provide at the home when they first take up employment. The home is not achieving the required levels of qualified staff and as such service users are not being supported by the most effectively trained staff team possible. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that a staffing review takes places that establishes how many hours of care and support service users require (to include social and recreational suppport) and how those hours are being met by the numbers of staff currently on duty. This review must be sent to the Commission and another requirement that the Registered Manager must ensure that there are sufficient staff on duty at all times to ensure that all service users needs are met. The manager stated that the required staffing levels for the number of service usrs are always in place but a detailed review based on hours of need has not been conducted. Staff Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 20 reported on difficulties with staffing given that there is ony one lounge and although they may have the required number of staff per floor, the fact that they have to split those staff between service users on the ward and those who may be using the ground floor lounge means that a lot of time is lost travelling between the floors. Staff also said that the needs of the majority of service users means that often the basic levels of staff are not enough. At one point on the inspection, care staff had to ask a cleaner to check who was ringing their call alarm as they were busy with another service user. The current staffing levels are around one member of staff to five service users. The previous requirement for a detailed review of staffing based on actual service users’ needs is repeated (See Requirements 13 & 14) There was a previous requirement that the Registered Individuals must ensure that 50 of non-nursing care staff hold the NVQ Level 2 in Care. Six out of the twenty non-nursing staff are undertaking or already hold the NVQ Level 2 in Care and the requirement is repeated. (See Requirement 15) Although there is a checklist in place for new staff to complete when they have undertaken parts of their induction, this currently does not comply with the Skills For Care (previously TOPSS) requirements of an Induction and Foundation programme. (See Requirement 16) There is an in-house core training programme in place that is offered to staff every three months. This includes customer care, nutrition for the elderly, infection control, catheter care, continence management, pressure area care, diabetic care, falls management and dementia in the elderly. The manager said that dementia care is an area they are currently looking to train the staff team in more thoroughly. The manager has audited staff training since he has taken up employment and it appears that the core statutory training has been completed by most staff. There are certain areas of training that have not yet been offered that are necessary for staff to fully meet service users’ needs. (See Requirement 17) The manager has audited staff files and has a list of any missing documentation. Letters have been issued to staff reminding them to bring in copies of any required information. Given the newness of this manager it would be more useful to fully audit the recruitment files at the next inspection. Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 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 The home is now managed by a permanent person who showed on this inspection that they fit to be in charge. They have not yet applied to be registered with the Commission. The home is not evidencing that it is run in the best interest of the service users and there is not a consistent appropriate level of satisfaction with the home. The record keeping procedure is not being maintained and service users’ information is not being held securely. Although generally the health and safety of service users is being maintained they are being placed at some risk by the treatment room not being locked at all times. EVIDENCE: Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 22 There was a previous requirement that the Registered Individual must ensure that the new manager puts in an application with the Commission to become Registered Manager as soon as they commence employment. This has not occurred and is repeated. (See Requirement 18) There was a previous requirement that the Registered Manager must ensure that service users and their families are consulted about their satisfaction with all aspects of life at the home and that a development plan is drawn up (to be reviewed at least annually) that addresses any issues raised. The organisation has a quality assurance policy that outlies the procedures in place for gathering service users’ views. The manager said that a questionnairre has been sent out recently but has not been received back yet. The manager thought that the home had an annual development plan that was based on these surveys but given that he is relatively new in post, did not fully know about these systems as yet. Given the lack of evidence in the home the requirement is reperated. (See Requirement 19) There was a previous requirement that the Registered Manager must ensure that the cabinets containing service users files are kept locked at all times. One cabinet was again open on the day of the inspection. (See Requirement 20) There was a previous requirement that the Registered Manager must ensure that all doors required to be locked to maintain the health and safety of service users, are kept locked when not in use. The door to the lift motor room in the home was open. (See Requirement 21) Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 2 2 2 X X 2 3 STAFFING Standard No Score 27 2 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X X Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 24 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 OP7 Regulation 12(2)(3) 15 Requirement The Registered Manager must ensure that all care plans are consistent, written with the involvement of the service user and reviewed monthly as required. Unmet requirement: Previous timescale 30/11/05 The Registered Manager must ensure that service users are consulted about their preferred times of getting up and going to bed, that this is recorded in their care plan and that in practice this is carried out by staff. Unmet requirement: Previous timescale 30/11/05 The Registeerd Manager must ensure that stock checking procedures ensure that accurate records are maintained of all medication held in the home at any time. The Registered Manager must ensure that staff respect service users’ privacy and dignity at all times particularly in the areas of knocking on doors before they enter and not speaking about other service users’ issues in DS0000007012.V264414.R01.S.doc Timescale for action 31/03/06 2 OP7OP8 15 31/03/06 3 OP9 13 (2) 31/12/05 4 OP10 12 (4) (a) 31/12/05 Camberwell Green Nursing Home Version 5.0 Page 25 5 OP11 12(a) 15 6 OP12 16(2)(m) & (n) 7 OP14 16(2)(i) 12(3)&(4) (b) 8 OP16 22 9 OP18 13(6) 18(1)(c) (i) 12 (4) (a) 10 OP20 front of people. The Registered Manager must ensure that all agreed guidelines and procedures in the event of someone’s dying and death are clearly recorded in the service users’ files/care plans The Registered Manager must ensure that a consultation is carried out with all service users as to what activities they would choose to engage with on a dayto-day basis. The results of this survey must then lead to an individual programme of activities support being drawn up in the care plan and offered to each service user. Unmet requirement: Previous timescale 30/11/05 The Registered Manager must ensure that a consultation takes place around the issue of food at the home that includes reference to cultural, ethnic and other preferences and that the results of this consultation are acted upon. Unmet requirement: Previous timescale 30/11/05 The Registered Manager must ensure that a record is maintained of all informal complaints and concerns in order that pattrens of concerns can be audited and action can be taken and recorded in response to any issues. The Responsible Individuals must ensure that all staff attend training around protection of vulnerable adults. The Registered Manager must arrange for service users to be provided with keys to their rooms unless their risk assessment suggests otherwise or they choose not have them. Unmet requirement: Previous DS0000007012.V264414.R01.S.doc 31/01/06 31/03/06 31/03/06 31/03/06 31/03/06 31/01/06 Camberwell Green Nursing Home Version 5.0 Page 26 11 OP21 12(3) 23(2)(d) 12 OP22OP25 23 (2) (n) 13 OP27 18 (1) (a) 14 OP27 18 (1) (a) 15 OP28 13(6) 18(1)(c) timescale 30/04/05 & 30/11/05 The Registered Manager must ensure that work is carried out on all the toilets and shower/bathrooms to decorate them in a manner that is noninstitutional, chosen by the service users and as homely as possible given the equipment that may need to be kept in some of them. Unmet requirement: Previous timescale 31/12/05 The Registered Individuals must ensure that an occupational therapists assessment (or equaivalent) of the building and all equipment and adaptations within it is carried out to ensure that service users are safe and receiving the most appropriate specialist support. Any recommmendations made in the report must be addressed. Unmet requirement: Previous timescale 31/12/05 The Registered Manager must ensure that there are sufficient staff on duty at all times to ensure that all service users needs are met. Unmet requirement: Previous timescale 31/01/06 The Registered Individuals must ensure that a staffing review takes places that establishes how many hours of care and support service users require (to include social and recreational suppport) and how those hours are being met by the numbers of staff currently on duty. This review must be sent to the Commission. Unmet requirement: Previous timescale 31/12/05 The Registered Individuals must ensure that 50 of non-nursing DS0000007012.V264414.R01.S.doc 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Page 27 Camberwell Green Nursing Home Version 5.0 (i) 16 OP30 18(1)(c) (i) 17 OP30 18(1)(c) (i) 11(1)CSA 18 OP31 19 OP33 12(3) 24 20 OP37 17(1)(b) 21 OP38 13(4)(a) (c) care staff hold the NVQ Level 2 in Care. Unmet requirement: Previous timescale 31/12/05 The Responsible Individuals must ensure that there is an Induction and Foundation programme in place that covers the requirements of the Skils For Care (previously TOPSS) standards. The Responsible Individuals must ensure that staff attend training around Care Planning and End of Life Care. The Registered Individual must ensure that the new manager puts in an application with the Commission to become Registered Manager as soon as they commence employment. Unmet requirement: Previous timescale 30/09/05 The Registered Manager must ensure that service users and their families are consulted about their satisfaction with all aspects of life at the home and that a development plan is drawn up (to be reviewed at least annually) that addresses any issues raised. Unmet requirement: Previous timescale 31/12/05 The Registered Manager must ensure that the cabinets containing service users files are kept locked at all times. Unmet requirement: Previous timescale 14/09/05 The Registered Manager must ensure that all doors required to be locked to maintain the health and safety of service users, are kept locked when not in use. Unmet requirement: Previous timescale 14/09/05 31/03/06 31/03/06 31/12/05 31/03/06 31/12/05 31/12/05 Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 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. Refer to Standard Good Practice Recommendations Camberwell Green Nursing Home DS0000007012.V264414.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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