CARE HOMES FOR OLDER PEOPLE
Carshalton Nursing Home 28 Salisbury Road Carshalton Surrey SM5 3HD Lead Inspector
Alison Ford Key Unannounced Inspection 18th July 2007 10:40a 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 Carshalton Nursing Home DS0000019081.V345968.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. Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Carshalton Nursing Home Address 28 Salisbury Road Carshalton Surrey SM5 3HD 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) 020 8669 2592 020 8669 9558 sweethomes@aol.com Sweet Homes Ltd Post Vacant Care Home 33 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A maximum of 10 service users may be in the DE(E) category. Date of last inspection 31st January 2007 Brief Description of the Service: Carshalton Nursing Home is registered to provide care for up to thirty-three older people who may have dementia however; reluctance by the local authority, to place clients in shared rooms has lead to a decrease in the number of residents in the home. As an existing care home some of the facilities would not meet the requirements of a newly registered home. A large proportion of the accommodation is provided in shared rooms, without en-suite facilities and they are smaller than would now be acceptable. There is only one lounge/dining area and this is in the form of a conservatory, which despite fans is sometimes uncomfortably hot. There is a shaft lift to ensure accessibility throughout the home and the conservatory overlooks the rear garden. There is limited off-street parking however the home is in a quiet road and close to public transport links. At the time of this inspection fees range were £550 per week. A copy of the homes Statement of Purpose, Service User Guide and the latest inspection report can be obtained from the homes Registered Providers or the latter can also be obtained from the Commission For Social Care Inspection. Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes first key inspection visit as part of the inspection process for the year 2007/2008 and was unannounced. When writing the report consideration has also been given to other information gathered throughout the year such as, records of accidents and complaints and other documentation required to be kept by the home. There have also been conversations with residents, their relatives and members of staff. Prior to this visit, the homes management team had submitted an Annual Quality Assurance Assessment. This is a “self assessment “ document that they are required to complete, in order to supply The Commission with details about how well they consider that they are providing a service for the people that they are supporting. On the day of the visit there were 16 residents living in the home. Two trained nurses were on duty with three care staff and a cook, a laundry assistant and a domestic assistant. At the last inspection the Registered Manager had recently retired and the registered providers were in the process of recruiting a suitable applicant to fill this post. A trained nurse has been recruited as the acting manager however an application has not as yet been submitted to The Commission for consideration for registration. During the visit, a partial tour of the premises was undertaken; a sample of care plans were assessed, documentation relating to health and safety was seen and several of the residents and one relative, who was visiting, were spoken with. No complaints have been received about this service since the last inspection. What the service does well:
This home aims to provide a caring homely environment for older people, the majority of whom have advanced stages of dementia. Staff turnover is very low which contributes to a stable and familiar environment and staff members had previously commented, “ it was like being a part of a big family “. There is always at least one trained nurse on duty in the home supported by care staff, in sufficient numbers to ensure that resident’s needs are met and to
Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 6 enable carers to spend time talking with them. A key worker system encourages a close relationship between the residents and individual staff members The majority of those residents that were spoken with were unable to express their opinions about the care and services provided by the home however they looked generally clean, well cared for and comfortable. The lunchtime meal was served during the course of the inspection, it was well presented, looked appetising and all of them seemed to enjoy it. Pre-admission assessments undertaken by a senior member of staff ensure that residents can be confident that their healthcare needs will be met and all of them receive a contract and Service User Guide when they move into the home. All residents have an individual plan of care, setting out the support and interventions that are needed and these are reviewed regularly to ensure that they reflect the care that is currently required. The majority of the staff have received training in dementia and its associated problems, which has heightened their awareness of the healthcare needs of the residents and during the visit they were seen to be interacting well with residents. A limited range of activities are provided although, several residents are unable or choose not to join in. Visitors would always be made welcome into the home. Not all of the relevant documentation to show that the home is run in the best interests of those living there was available for inspection and this will need to be provided. What has improved since the last inspection? What they could do better:
Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 7 The home still requires significant investment in order to meet all of the minimum standards. Unfortunately the layout of the building means that corridors are dark and would be confusing to elderly people with dementia and signage needs to be improved to help orientate them. Some redecoration is still needed, paintwork is damaged and much of the furniture is worn and shabby. The garden does not provide a pleasant place for residents to enjoy the warmer weather; there are no flowers or garden furniture and there is still a pile of rubbish in the corner. Several areas of the home were malodorous on the day of this latest inspection. Some concerns were raised about the privacy and dignity of residents. It is possible to see into a downstairs bedroom from the street and it would seem that one of the resident’s bedrooms is being used as a staff changing room. Much of the documentation that is produced by the home for the people who live there is not in a format that they would be able to understand. There are also people using the service who do not speak English. In order to improve communication and ensure that residents and their representatives can access all of the information that they need it must be produced in alternative formats such as audio or pictorial. There is a limited range of activities organised by the home to offer stimulation and interest to the people living there and these must be increased in line with their remaining capabilities and their interests. Improvements in the preadmission assessment process would help to identify activities that might interest residents. There is very little opportunity for them and their families to influence the care and services that are provided and additional ways for them to become more involved must be explored. Some of the documentation that the home is required to keep as evidence of its commitment to the health and safety of its staff and resident was not available for inspection although the providers self assessment stated that it was in place. In future this must be made available even though inspection visits are not announced and this issue will need to be addressed. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Carshalton Nursing Home DS0000019081.V345968.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 Carshalton Nursing Home DS0000019081.V345968.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3,6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use this service are still not able to access all of the information that they need to help them decide whether living this home will suit them. A pre-admission assessment ensures that their healthcare needs can be met however their social needs and preferences are not taken into account. This home does not offer intermediate care. EVIDENCE: The local authority funds the majority of the current residents and the care manager’s assessments, determining the level of support that is required were seen in care plans that were assessed. In addition a senior member of the homes staff will visit a potential resident to make certain that their needs can be met. Assessment of these showed that social needs and preferences are not considered in any great detail so, although records show that medical needs
Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 10 can be addressed there is no evidence to show that residents particular interests can be catered for or that activities will be provided which interest them. Despite previous requirements, the Statement of Purpose and Service User Guide remains as one document. Although a copy is in resident’s rooms the format means that it would provide a useful tool for very few of them. Alternative formats such as audio or, pictorial, as some residents do not speak English, must be considered and there must be two distinct documents. A clear Statement of Purpose must be available for the home, which complies with Regulation 4 of The Care Homes Regulations and identifies the objectives and philosophy of the home. In this way The Commission and those people who use the service will be able to measure how well the home meets its stated aims. In addition, a written guide to the home, which will include a summary of The Statement of Purpose and a description of the services being offered, must support this and be made available to residents. Information relating to fees must also be included in this in line with Regulation 5 and it must reflect the current situation in the home with regard to staffing. There is also a small leaflet available detailing services offered in the home however, this is out of date and must be revised if it is to be used. Carshalton Nursing Home DS0000019081.V345968.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use this service have an individual care plan, so that generally, their health care needs are identified, and regular review ensures that they reflect the interventions and support currently needed. Staff attitudes within the home respect the privacy and individuality of residents and allow them to retain their dignity. Medication policies and procedures, designed to protect residents and ensure their safety, are in place within the home. EVIDENCE: All residents have an individual care plan of which three were seen. These included those of two of residents recently admitted to the home.
Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 12 They are based on a nursing model; ”Ropers Activities of Daily Living” and include risk assessments, assessment of skin integrity, nutritional screening and the identification of those most at risk from developing pressure sores. The Registered Providers self-assessment states that all special needs and preferences are built into care plans however there was little information available about resident’s social needs and preferences. Two residents do not speak English and some pictorial help is available however, this is very limited and must be increased. There was also some concern about the lack of a care plan for a resident with diabetes. Care must be taken to ensure that all identified problems have a care plan. There is still no evidence available to indicate resident’s preferences in the event of then becoming unwell or their death. Photographic evidence is used to monitor wound healing and pressure-relieving equipment was seen in use throughout the home. Previous inspections recommended that to safeguard both the home and the resident a consent form should be signed by the resident or their representative prior to this being done. This does not seem to have been done and now becomes a requirement. Advice is sought from the Tissue Viability Nurse Specialist as needed for the best treatment of pressure sores and there is also evidence in the care plans of visits from other members of the multidisciplinary health care team. Staff were seen interacting with residents in a kind and respectful manner and they were able to spend time talking with them. Most resident’s sit together in the lounge and this creates a very homely atmosphere. Personal care would be delivered in their own rooms. Those residents who were able to express an opinion and relatives that were spoken with agreed that they felt that resident’s healthcare needs were well met in this home. Medication records and storage was seen and appeared to be in order. Trained nurses administer all of the medication in the home and once again they were reminded that opened bottles of eye drops should be labelled on the bottle rather than the box in order to minimise the risk of any errors occurring. It was also noted that opened bottles of insulin were being stored in the fridge although the data sheets indicate that it should not be. A new medication policy has been drawn up and staff have signed to say that they have read it. Lack of IT equipment means that the policy has been Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 13 handwritten. Administrative support must be provided so that this can be produced in a more suitable format. Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use this service enjoy varied and balanced meals, which are attractively presented to them and their friends and visitors, would always be made welcome however, opportunities for them to exercise choices in their daily lives are not maximised. EVIDENCE: The advanced stages of dementia of many of the residents in this home mean that there are restrictions on the amount of choices that they can make and although staff said that they are encouraged to do so where possible there are areas where this could be improved. It was noted however that two residents do not speak English and the provision of pictorial prompts is limited. These must be developed further. Picture menus could also be introduced which would help all the residents choose what they would prefer to eat. Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 15 The lunchtime meal was served during the inspection and looked appetising and well presented. All the residents were given a drink with lunch and there were sufficient staff to help those who required it. Several residents require their food to be pureed and this, too, was presented in an attractive way. However, it was noted that at times this was all stirred up together. Menus were also seen which appeared varied and well balanced although they did not appear to correspond with the menu. A book now reflects the food actually served on the day. The cook is made aware of resident’s particular preferences and dislikes and a choice of meal would always be offered. It is recommended that a list should be available in the kitchen so that everyone is aware of resident’s particular likes and dislikes On the day of the inspection the majority of residents were sitting in the lounge and staff do sit and talk with them. However, apart from one music session a week this would seem to be the extent of activities provided. A record is kept, although this only confirmed the absence of any other form of stimulation. An effort must be made to try and discover more about residents past interests and a suitable activities programme must be introduced for them. Visitors would always be welcome into the home and they are encouraged to visit. It is recommended that social events could be held within the home to which they could be invited. It is accepted that very few of the residents would be able to participate in trips out of the home. Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People who use this service benefit from a clear complaints policy, however it has not been produced in a format, which suits their need and abilities. Appropriate procedures to deal with abuse and discrimination are in place to ensure that residents are safe living in this home. EVIDENCE: There is a complaints procedure in use in the home; it is outlined in the service user guide, a copy of which is in all the residents’ rooms. However this would not be able to be accessed by any of the residents and, as with other documentation intended for residents, an alternative format must be considered. There is a supply of forms for residents, or any visitors to the home, to record any issues of concern on the table in the entrance hall. These individual forms could easily become mislaid and a more secure way of keeping these must be found. Three new members of staff have been employed since the last inspection. Staff files were not on the premises and therefore it was not possible to ensure
Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 17 that appropriate checks had been made prior to their employment. The provider’s self-assessment stated that all necessary clearance is always obtained however copies of this must be kept in the home for inspection. The Registered Provider was contacted about this at the time. Some staff have received recent training in issues around adult and another session has been booked. Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use this service still do not live in an environment, which suits their needs and there are some concerns regarding their safety. EVIDENCE: A tour of the premises was undertaken. The Registered Providers selfassessment states that a full programme of redecoration and refurbishment has now taken been completed. While it is acknowledged that some redecoration has taken place and some of the armchairs and carpets have been replaced the home remains a less than ideal environment for residents with dementia to live in.
Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 19 Many of the bedrooms would not meet the standards expected of a new home, corridors are dark and paintwork is chipped and worn. There is no increased signage that would help the residents orientate themselves. Some of the chairs and furniture in the entrance hall and lounge are worn and shabby and bathrooms need to be refurbished and upgraded. Radiators in the lounge are not guarded. Staff uniforms and shoes in one residents bedroom suggest that it is being used as a staff changing room, thereby compromising their privacy. A front bedroom has no net curtains and the resident would be fully in view of anyone passing by the home. The garden still does not provide a pleasant area for residents. There are no flowers, the grass needs cutting, there is no garden furniture and a pile of rubbish is in the corner. All designated fire doors are fitted with automatic closers, which operate in the event of a fire to maintain the health and safety of residents however, it was noted that a side door had been left wide open. This left the laundry accessible and as the gate to the front of the property only has a bolt on there is a possibility that residents could leave the home unnoticed. Considering that an incident occurred in the past where a resident left the home and fell, this door must be kept shut. The outside gate must also be fitted with a more secure lock although it must easily be openable in the event of a fire. New panels have been fitted to the roof of the conservatory so that it is not so hot for residents sitting there. The front door is now protected by a keypad system although this is not linked to the fire alarm and ideally should be, so that it would release when the alarm is activated. Several areas of the home were malodorous on the day of the inspection. Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use this service can be sure that there are sufficient numbers of staff on duty in the home to ensure that their needs will be met however there is limited evidence that that staff training and recruitment procedures are in place to protect them. EVIDENCE: The off duty rotas were seen and showed that there were always trained nurses on duty in the home and they are supported by enough care staff to be able to meet the residents needs and, in addition, laundry and domestic staff are on duty. The majority of staff have undertaken a distance-learning package in dementia care and in infection control. Statutory training has been provided although any staff member wishing to access any other training has to do so independently. In order that residents benefit from care that is delivered according to current best practice guidelines, staff must be given the opportunity to access training that is relevant to the needs of those that they care for. The majority of care staff have an NVQ level 2 qualification.
Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 21 There is an induction programme in place for all new members of staff. All staff training is still recorded in a book which was seen however, it was recommended that a training needs analysis should be complied so that it was easy to identify any future training needs. It was noted that all of the documentation that was being used for induction and supervision was photocopied and not of a good quality. It is recommended that this should be improved in order to reflect its importance to staff. At this inspection as at the last, there was no evidence that a Criminal Records Bureau check had been obtained for new members of staff. The provider’s selfassessment indicated that appropriate clearance is always obtained; in future this documentation must be available to be seen at inspection visits. The Registered Provider was contacted about this issue as a matter of urgency. Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,36,38 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People who use this service cannot be sure that it is managed in their best interests. There is no evidence that they are able to influence the services that they receive or contribute to the running of the home. Some working practices do not ensure that their health and safety are fully protected. EVIDENCE: The home is still without a Registered Manager, the previous manager having retired, although a trained nurse is currently fulfilling this role in an acting capacity. This role is essential to provide leadership for staff and continuity of care for residents and an application must be made as soon as possible for registration of a suitable person.
Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 23 Despite previous requirements there was still no evidence that any form of quality assurance monitoring is undertaken in the home. Staff that were spoken with thought that questionnaires were sent out every six months however they did not have any information about the results of these. A system to measure the satisfaction of those living in the home and their relatives must be introduced and the results used to influence the provision of future services. The wife of the Registered Provider visits the home on a regular basis however no records are available of these visits. Written reports of these visits must be prepared in accordance with Regulation26 and made available for inspection. Some supervision of care staff is now happening although it is mainly observational. Trained nurses watch the care staff as they undertake various healthcare tasks and identify any areas where training may be required. There does not appear to be any opportunity for one to one discussion regarding performance, policies and procedures. Supervision does not seem to be in place for trained staff. All staff must be able to access supervision in order for them to discuss their development and practice and to identify any training needs that they may have and those who are supervisors must be given the opportunity to attend relevant training in order for them to undertake this role. A selection of certificates showing that equipment is appropriately maintained was seen however, as at the last inspection, there was no evidence that electrical safety checks or portable appliance testing had been done. The provider’s self-assessment states that all of the required checks have been undertaken however; evidence of this must be available in the home for inspection. There was also no evidence that a fire risk assessment had been undertaken in line with current legislation. If this has not yet been undertaken it is recommended professional help should be considered in order to complete it. Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X 2 X 1 Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 and 5 Requirement There must be a clear Statement of Purpose and Service User Guide produced for the home, which complies with the regulations. This must be produced in a format that is suitable for the people for whom it is intended. Pre-admission assessments must contain evidence that the social needs and preferences of people have been considered so that they can be sure that life in the home will suit them. There must be evidence that the communication needs of those people who do not speak English are being met. There must be evidence that all of the healthcare needs of residents have been identified and the support that they require has been considered. Where photographic evidence is used there must be evidence that permission has been obtained from residents or their representatives. All medication must be stored
DS0000019081.V345968.R01.S.doc Timescale for action 30/10/07 2 OP3 14 30/10/07 3 OP8 4(b) 30/10/07 4 OP8 4(b) 30/10/07 5 OP8 4(a) 30/10/07 6 OP9 13(2) 30/10/07
Page 26 Carshalton Nursing Home Version 5.2 7 8 OP9 OP12 13(2) 16(2)(n) 9 OP16 22(2) 10 11 OP16 OP18 22(2) 19 and labelled correctly. The updated medication policy must be presented in a more appropriate format. The range of activities offered to residents must be increased to provide more interest and stimulation to their day. The complaints policy must be produced in a format that is more suitable for the people who live in the home. A more secure way of recording complaints that are made must be found. There must be evidence available for inspection to show that appropriate preemployment checks are being made. (Previous timescale 30/05/07 not met.) Worn and chipped furniture must be replaced. The redecoration and refurbishment programme must continue. Increased signage must be provided to help orientate the people living in the home. All radiators in the home must be guarded to prevent residents from burning themselves. Resident’s bedrooms must not be used as changing rooms. The garden must be made a more pleasant area for residents to use. The gate to the side of the home must be secured so that residents would not be able to get out unnoticed. The side door must be kept locked so that residents are not able to get out unnoticed. All parts of the home must be
DS0000019081.V345968.R01.S.doc 30/10/07 30/10/07 30/10/07 30/10/07 30/10/07 12 13 14 15 16 17 18 OP19 OP19 OP19 OP19 OP19 OP19 OP19 23(2)(d) 23(2)(d) 23(2)(a) 13(4)(a) 23(3)(i) 23(2)(o) 13(4)(a) 30/10/07 30/10/07 30/10/07 30/10/07 30/10/07 30/10/07 30/10/07 19 20 OP19 OP26 13(4)(a) 16(2)(k) 30/10/07 30/10/07
Page 27 Carshalton Nursing Home Version 5.2 21 22 OP30 OP31 18(1)(c) 8(1) kept free from malodour. All staff must be able to access training appropriate to the work that they do. An appropriately experienced and qualified person must be put forward for registration as the manager for the home. (Previous Timescale 30/05/07 not achieved.) There must be evidence that the people who use this service are able to influence the care and services that are provided by the home (Previous timescale 08/11/06 not achieved) 30/10/07 30/10/07 23 OP33 24(1) 30/10/07 24 OP33 26 There must be evidence of visits undertaken in line with regulation 26. (Previous timescales 08/11/06, 30/05/07 not achieved 30/10/07 25. OP36 18(2) There must be documented evidence that all staff are receiving regular supervision. (Previous timescale 08/11/06,30/05/07 not achieved) 30/10/07 26. OP36 18(1)(c) 27. OP38 13(4)(c) All staff members who are delivering supervision must be able to access training in order to fulfil this role. There must be evidence available at inspection visits to show that all equipment and services have been regularly maintained and checked. (Previous timescale 30/05/07 not achieved) 30/10/07 30/10/07 Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 28 28 OP38 23(4) A fire risk assessment must be compiled for the home in line with current legislation. 30/10/07 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 3. Refer to Standard OP15 OP15 OP30 Good Practice Recommendations It is recommended that picture menus should be introduced to help residents choose the meals that they prefer. It is recommended that a list of the food likes and dislikes of each resident should be kept in the kitchen. It is recommended that a training needs analysis should be developed to make it simpler to identify further training required by individual staff members. It is recommended that documentation used in the home in conjunction with staff training and development should be produced in an improved format that reflects its importance. 4 OP30 Carshalton Nursing Home DS0000019081.V345968.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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