CARE HOMES FOR OLDER PEOPLE
Carshalton Nursing Home 28 Salisbury Road Carshalton Surrey SM5 3HD Lead Inspector
Alison Ford Key Unannounced Inspection 8th January 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Carshalton Nursing Home DS0000019081.V357277.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.V357277.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.V357277.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 Brief Description of the Service: Carshalton Nursing Home is registered to provide care for up to thirty-three older people who may have dementia. 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 from £525- £550 per week. Any extra charges payable for services such as hairdressing would be discussed prior to admission. 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 from their website. Carshalton Nursing Home DS0000019081.V357277.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 second 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 the previous 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 11 residents living in the home, most of them were sitting in the lounge. Two trained nurses were on duty with three care staff, a cook and a domestic assistant. Once again the home is without a manager however, the Registered Providers daughter has been given the responsibility for overseeing the running of the home. She is currently in the process of trying to appoint a suitable person to manage the service. During the visit, a partial tour of the premises was undertaken; a sample of care plans were assessed, documentation relating to the health and safety of residents and staff 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. The building is not ideal for people who are frail and confused, many of the bedrooms would not meet the standards expected of a new home and corridors Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 6 are dark and disorientating. There is limited communal space and one large conservatory serves as both a sitting and dining area. However, the atmosphere within the home is very pleasant and friendly. Staff turnover is low, many of them have been there for several years, and this contributes to the stable and familiar environment. Staff members say, “ it is like being a part of a big family “ and they know the residents and their families well. Most of the people who live in the home are not able to tell us how they feel about the care and services that are provided but they look clean, well cared for and comfortable. One resident, who had recently been admitted, was able to talk to us about the experience and said “it is really nice in the home, staff are lovely and very kind and there is always plenty of food and it tastes homemade”. They told us that “Their room was really nice, always clean, and staff will always bring you an extra cup of tea or a little snack if you ask them”. A visitor that was spoken with also said that she always found the staff welcoming and approachable and she thought that residents always seemed to be well looked after. She particularly commented on how clean the home always was. There is always at least one trained nurse on duty in the home supported by care staff. As the majority of residents sit together in the lounge, the staff are able to spend time chatting with them and this contributes to the cheerful atmosphere within the home. Pre-admission assessments, undertaken by a senior member of staff, ensure that people who move into the home can be confident that their healthcare needs will be met and all of them receive a contract and Service User Guide. They have an individual plan of care, setting out the support that they need and these are reviewed regularly so that any changes are identified. The majority of the staff have received training in dementia and its associated problems and this helps them to understand the needs of the people that they are caring for. A limited range of activities is provided for residents and their visitors would always be made welcome into the home. What has improved since the last inspection?
Since the last inspection the Registered Provider has appointed his daughter, Ms Dimple Joshi, to oversee the running of the home. She has been made aware of the shortfalls within the home and is confident of her abilities to address them.
Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 7 This has been taken into consideration when undertaking the inspection and although some of the issues that have been raised have resulted in requirements being repeated, where there is no direct impact on the wellbeing of those using the service, timescales have been extended. Ms Joshi visits the home regularly and there are records of her visits and the areas of the home that she has looked at on each visit. Redecoration and refurbishment is already underway. Carpets and net curtains have been replaced and other curtains are waiting to be put up. Security issues have been addressed so that residents are not able to wander out of the home on to the street. Picture menus are being developed to help those who are confused, or may have trouble communicating. Staff training is currently being arranged in order to deliver mandatory training sessions throughout the coming year and make sure that all staff members are kept updated. What they could do better:
Although redecoration and refurbishment has started in the home this must now continue in order to make sure that the home is a pleasant place for people to live in. The garden also still needs some attention, so that residents will be able to sit out there when the weather becomes warmer. To ensure the safety of people who are using the service, radiators that are in the lounge need to be guarded, so that residents do not burn themselves and regular checks must be made to make sure that bedroom doors all shut completely when the fire alarm is activated. Care plans still need to reflect resident’s previous lives and achievements. This will help staff understand their current behaviour and also help them to plan activities that will be suitable and provide interest and stimulation. Some method of gaining the views of people who use the service must also be found so that they can influence the way that the home is run. Consideration also needs to be given to producing documentation that is intended for residents and their relatives in a format that makes it easier for them to read and understand. Not all of the relevant documentation to show that the home is run in the best interests of those living there was available to be assessed. The Annual Quality Assurance Assessment states that this is all in place however evidence of this must be kept in the home and made available for inspection. Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 8 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.V357277.R01.S.doc Version 5.2 Page 9 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.V357277.R01.S.doc Version 5.2 Page 10 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 adequate. 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 the two care plans of residents admitted since the last inspection.
Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 11 In addition a senior member of the homes staff had visited them to make sure that their needs could be met. It was noted that social needs and preferences are still not considered in any great detail so, although records show that medical needs can be addressed there is no evidence 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, should 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 is meeting 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. Although these issues were identified at previous inspections, given the recent change in the management structure of the home the timescale for compliance has now been extended. Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 12 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 good 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 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 the residents have an individual care plan of which three were seen. They included those of two of residents recently admitted to the home. They are based on a nursing model; ”Ropers Activities of Daily Living” and include risk assessments, assessment of skin integrity, nutritional screening
Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 13 and the identification of those most at risk from developing pressure sores. Input is sought from other healthcare professionals as needed and domiciliary dentists and opticians visit residents regularly. Some pictorial prompts have been developed to help communicate with people in the home who do not speak English. Most of the people who live in this home would not be able to contribute to the care planning process however, there is evidence that staff have explained them to their relatives and that they are kept informed of any changes. It was noted that there is still very limited information available about resident’s previous lives and achievements and their social needs and preferences. Collecting this information will give staff a greater understanding of the needs and behaviour of the people that they are caring for and also help them to plan activities that will interest them. Pressure-relieving equipment was seen in use throughout the home and photographic evidence is used to monitor wound healing. 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 has now been done. 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 is always delivered in resident’s own rooms. Trained nurses administer all of the medication in the home and medication records and storage were all in order. Carshalton Nursing Home DS0000019081.V357277.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 good. This judgement has been made using available evidence including a visit to this service. The people who use this service generally enjoy a lifestyle, which meets their needs. They have varied and balanced meals, which are attractively presented to them and their friends and visitors are always welcome. They might benefit from an increase in suitable activities planned to suit their interests and remaining capabilities. EVIDENCE: Most of the people who currently live in this home have dementia, which means that the choices that they can make are limited although staff say that they are encouraged to do so wherever it is possible. Residents that we spoke with, that were able to express an opinion, agreed that routines within the home were flexible and that they were able to choose what time they got up or went to bed, the clothes that they wore and there was always a choice of meal should they want it. Picture menus and pictorial prompts are being produced which help them.
Carshalton Nursing Home DS0000019081.V357277.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. Menus were also seen which appeared varied and well balance. The cook is made aware of resident’s particular preferences and dislikes, she speaks with residents every morning and a choice of meal would always be offered. 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. More work must be undertaken to provide an activities programme, which will suit the remaining capabilities of residents and offer interest and stimulation. Given the cognitive impairment of the majority of the residents it is recommended that professional guidance should be sought to help with this. 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 however one resident is able to go out regularly with her relative. Carshalton Nursing Home DS0000019081.V357277.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 adequate 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, although 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 but procedures, which prevent unsuitable people from working in the home, are not always followed. 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 few of the residents would be able to understand it. As with other documentation intended for residents, an alternative format should 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. It is also recommended that a copy of the complaints procedure should be prominently displayed in the entrance hall. No complaints have been made about the service since the last inspection.
Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 17 One new member of staff has been employed since the last inspection. Records showed that she had actually begun working in the home before the necessary pre-employment checks had been completed. The management team were reminded of their responsibilities with regard to this. 50 of staff have received recent training in issues around adult abuse and another session has been booked for all other staff. Carshalton Nursing Home DS0000019081.V357277.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 adequate This judgement has been made using available evidence including a visit to this service. People who use this service live in a clean safe environment, although it would not meet the current standards. EVIDENCE: This home remains a less than ideal environment for residents with dementia to live in. 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. There is one
Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 19 communal area, which serves as both sitting and dining area, and it is difficult to maintain an ambient temperature in this room, it is often quite hot. Radiators in the lounge are still not guarded, posing a risk to any resident who is able to walk around unaided. It is however acknowledged that a programme of redecoration has begun. Some furniture and carpets have been replaced, new net curtains have been put up and new curtains are in the process of being put up in resident’s bedrooms. Pictures have also been purchased. Therefore the timescales for improving the presentation of the home have been extended. It is recommended that, where bedrooms that were originally intended to be for double occupancy and are now designated as single rooms, dividing curtains and rails should be removed to give residents more space. The garden was tidied up following previous inspections however; there are still piles of unwanted equipment left in corners. It requires some attention to make it a pleasant place for residents to sit in the summer and it is recommended that some flowers and garden furniture should be purchased before the warmer weather. 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 they do not all shut fully when released. These must be checked regularly to make sure that they are always fully operational. On the day of the inspection the home was clean and tidy and generally free from malodour. Carshalton Nursing Home DS0000019081.V357277.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 adequate 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 and that staff training is improving. Recruitment procedures do not always protect residents from staff who have been judged as unsuitable to be working with vulnerable people. EVIDENCE: The off duty rotas were seen and showed that there are 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 and a training plan is in place for the forthcoming year. This will include medication awareness, fire safety, dementia and food hygiene. The majority of care staff have an NVQ level 2 qualification. Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 21 The recommendation to develop training needs analysis to make it easy to identify which members of staff have undertaken various courses and who still needs training is repeated. One new member of staff had been recruited since the last inspection. Records showed that recruitment checks had not been completed prior to her starting work and the management team were reminded of their responsibilities in this process. Appropriate clearance has now been received. Carshalton Nursing Home DS0000019081.V357277.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 31,33,35,36,38 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 are not able to influence the services that they receive or contribute to the running of the home. They do not benefit from the leadership skills that would be provided by a registered manager and there is not always evidence to show that equipment and services are properly maintained. EVIDENCE: This home is still without a Registered Manager. This role is essential to provide leadership and supervision 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.V357277.R01.S.doc Version 5.2 Page 23 The Registered Provider has nominated his daughter to take on the responsibility for the home and it is acknowledged that she is currently trying to appoint a suitable person to this role. Meanwhile senior trained nurses are ensuring that care staff are being appropriately supervised on a daily basis and are undertaking the day-to-day management of the home. However, there are still not any formal arrangements for staff supervision in place. This process is essential in order to monitor staff performance and identify future training needs. If the current attempt to recruit a new manager is unsuccessful senior nurses must be trained to deliver supervision for care staff. There is still no method in place to gain the views of the people who use this service. It is accepted that the majority of residents would not be able to contribute to this process however; an effort must be made to try and seek the views of relatives, and healthcare professionals who visit the home. Their comments could then be used to influence the provision of future care and services in the home. There are regular staff meetings held so that staff are all kept informed about any new developments in the home. Some money is held on behalf of residents, mainly for paying for personal services such as hairdressing. The records were seen and were correct and easy to understand. The money is kept securely in the office. The previous inspection noted that, although the Annual Quality Assurance Assessment stated that appropriate checks had been made on equipment in use in the home, certificates of worthiness had not been available to support this. This evidence is still kept in a central office. Copies of certificates relating to electrical safety, gas safety, and a recent environmental health inspection of the kitchen must be forwarded to the local office of The Commission and, in future, copies of all of the certificates must be kept on the premises and made available for inspection. A fire risk assessment has been carried out and this too must be kept in the home. Fire alarms are tested on a weekly basis however, there did not appear to be a record of staff having attended fire safety training. Provision of this training must be given some priority and all staff must be given the opportunity to attend. Accidents are all appropriately recorded and the records of these were seen. Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Carshalton Nursing Home DS0000019081.V357277.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. Previous timescale 30/10/07 not met 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. Previous timescale 30/10/07 not met Residents care plans must contain more information about their past lives and achievements so that care staff are able to understand their present behaviours and plan activities that will entertain and stimulate them. Timescale for action 30/03/08 2. OP3 14 30/03/08 3 OP7 15 30/03/08 Carshalton Nursing Home DS0000019081.V357277.R01.S.doc Version 5.2 Page 26 4. OP12 16(2)(n) The range of activities offered to residents must be increased to provide more interest and stimulation to their day. Previous timescale 30/10/07 not met 30/03/08 5 OP16 22(2) The complaints policy must be produced in a format that is more suitable for the people who live in the home. Previous timescale 30/10/07 not met 30/03/08 6. OP16 22(2) A more secure way of maintaining the complaints record must be found. Previous timescale 30/10/07 not met 30/03/08 7. OP19 23(2)(d) The redecoration and refurbishment programme must continue. All radiators in the home, including those in the lounge, must be guarded to prevent residents from harming themselves. Previous timescale 30/10/07 not met 30/03/08 8. OP19 13(4)(a) 28/02/08 9. OP19 23(2)(o) Unwanted equipment must be removed from the garden and it must be made a more pleasant area for residents to use. Previous timescale 30/10/07 not met 30/03/08 10. OP19 13(4)(c) Automatic fire doors must be checked regularly to make sure that they are always fully operational.
DS0000019081.V357277.R01.S.doc 28/02/08 Carshalton Nursing Home Version 5.2 Page 27 11. OP29 19(1) No new member of staff may start work until all of the necessary checks have been completed so that people who have been judged as not being suitable to work with vulnerable adults are not employed. An appropriately experienced and qualified person must be put forward for registration as the manager for the home. Previous Timescale 30/05/07 and 30/10/07 not achieved. 08/01/08 12. OP31 8(1) 30/03/08 13. OP33 24(1) 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 timescales 08/11/06,30/10/07 not achieved 30/03/08 14. OP36 18(2) There must be documented evidence that all staff are receiving regular supervision. Previous timescale 08/11/06,30/05/07,30/10/ 07 not achieved 30/03/08 15 OP38 13(4)(c) Copies of certificates relating to the maintenance of gas and electricity and a copy of the report following the latest kitchen inspection must be forwarded to the local Commission for Social Care Inspection office.
DS0000019081.V357277.R01.S.doc 28/02/08 Carshalton Nursing Home Version 5.2 Page 28 16. OP38 13(4)(c) 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, 30/10/07 not achieved 30/03/08 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 OP16 OP30 Good Practice Recommendations It is recommended that a copy of the homes complaints procedure should be displayed in the entrance hall. It is recommended that a training needs analysis should be developed to make it simpler to identify further training required by individual staff members. Carshalton Nursing Home DS0000019081.V357277.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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