Inspection on 29/01/08 for Chapel View Nursing Home

This inspection was carried out on 29th January 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Chapel View Nursing Home 21/01/09

Chapel View Nursing Home 12/09/06

Chapel View Nursing Home 12/10/05

Chapel View Nursing Home 31/05/05

Chapel View Nursing Home 04/03/05

Chapel View Nursing Home 06/05/04

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Hawkhills

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Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Chapel View Nursing Home Spark Lane Mapplewell Barnsley South Yorkshire S75 6BN Lead Inspector Mike O’Neil Key Unannounced Inspection 29th January 2008 09:10 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 Chapel View Nursing Home DS0000006474.V337505.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. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chapel View Nursing Home Address Spark Lane Mapplewell Barnsley South Yorkshire S75 6BN 01226 388181 01226 380270 chapel.view@fshc.co.uk None Chapelfield View Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Lynda Jackson Care Home 39 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of Old age, not falling within any other category registration, with number (39) of places Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 60 years and above. There are 19 beds registered for nursing (N) and 20 for personal care (PC). 12th September 2006 Date of last inspection Brief Description of the Service: Chapel View is owned by Four Seasons Healthcare Limited. The home provides nursing and personal care and accommodation to thirty-nine older people. The home occupies a central position in the village of Mapplewell in Barnsley, close to shops, pubs, the post office and other local amenities. The home is a two-storey building. There are thirty-five single bedrooms and two double bedrooms. There is a passenger lift. The home has a garden area that was well maintained and accessible. A copy of the previous CSCI inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of monthly fees from 29th January 2008 were £341.50 - £612.50 per week. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This was an unannounced key inspection carried out by Mike O’ Neil and Sue Turner regulation inspectors. This site visit took place between the hours of 9:10 am and 3.40pm. Lynda Jackson, the registered manager and was present during the visit. Prior to the visit the manager Lynda Jackson had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. We also sent out surveys prior to the inspection, 3 were received back from professionals, 4 from relatives and one from a person who uses the service. Information from the surveys and AQAA is included in the main body of this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to 8 staff, one visiting health professional, 5 visiting relatives and 8 people who live at the home. We checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in September 2006. The progress made has been reported on under the relevant standard in this report. We wish to thank the people living in the home and the staff for their time, friendliness and co-operation throughout the inspection process. What the service does well: People said that the care they were receiving was good and consistently added comments such as ” the staff are nice, friendly and helpful”. Other comments made by people were “the staff are brilliant”, and “staff are lovely here” We saw that people were well dressed in clean, age appropriate clothing and attention had been paid to hair and nail care. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 6 Staff spoke to people in a respectful way and showed empathy and patience when providing personal care to people. People said that they had a choice of food and that the quality of food served was generally good. The building was clean and free from offensive odours. A good training and induction programme was in place for staff. What has improved since the last inspection? What they could do better: Peoples care plans need further attention and more detail so that the staff know what to do for each person. Staff need to follow what the care plan says so they can meet peoples care needs. Some areas of the home such as the corridors, lounges and bathrooms are showing signs of wear and tear and will need refurbishing in the near future. The home needs to be kept tidy and equipment should be stored appropriately. The staffing levels were insufficient which meant that some people’s needs were not being met. Some people did not have meals and drinks when they wanted them. Staff did not always have the opportunity to provide social contact and stimulation for people who were being cared for in their bedrooms. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 7 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. Chapel View Nursing Home DS0000006474.V337505.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 Chapel View Nursing Home DS0000006474.V337505.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): Standard 3.Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People were assessed prior to their admission to the service. These assessments enabled staff to be aware of peoples needs to ensure that they could be met. This home does not provide intermediate care services. EVIDENCE: Three peoples files were checked and each contained a copy of their full needs assessments. The information from the full needs assessment had been incorporated into the peoples care plans. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s care needs were documented in the care plans. However some of the identified staff interventions were not being followed, which meant that all of the people’s individual needs might not be met. Medication procedures protected people’s health and welfare. People’s privacy and dignity was maintained and promoted. EVIDENCE: Three peoples care plans were checked. The standard of the care plans were not satisfactory, and the information in them, was inadequate to ensure that people’s changing health, social and personal care needs could be met. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 11 • In two care plans checked peoples health needs were not being met because both people who were diabetic were not having their blood sugar levels monitored as required and highlighted in the care plan. The qualified nurse on duty was able to find evidence of one person’s blood sugar reading but there was only one recording on the persons record. Staff, when writing peoples daily notes, were not being reflective of the information actually recorded in the persons care plan. Therefore, there were no records to evidence that staff had met certain care needs of people for over 4 weeks. There was no evidence to suggest in two care plans that the person or their relatives were involved in the drawing up or the reviewing of the care plans. The care plans only contained limited or no information about people’s social needs. The activities coordinator said she had a separate file with this information in. This file/information was not available at the home when we visited. One person’s care plan contained good detail but some of the information was repeated making the document very bulky and difficult to track. The file contained 21 separate care plans with repeated information in the plans. Records should be condensed. This would make it easier for staff to use the care plan documentation and make it easier to monitor peoples changing needs. • • • • The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. Previous requirements relating to regular reviewing of peoples care plans and risk assessments were checked and had been met. Peoples weight was being monitored and appropriate equipment was available to safely weigh people. These were previous requirements made at the last inspection that had now been met. People said that the care they were receiving was good and consistently added comments such as ” the staff are nice, friendly and helpful”. Other comments made by people were “the staff are brilliant”, and “staff are lovely here” Relatives made comments such as “the staff are caring” and “the care here is good. “. Health care professionals said that the standard of care delivered at the home was good and that staff contacted them for advice and referred people when they were concerned about their condition. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 12 We saw that people were well dressed in clean, age appropriate clothing and attention had been paid to hair and nail care. Medicines were securely stored around the home in locked cupboards. The controlled drug cabinet was very full of controlled drugs. A larger or additional cupboard should be fitted to ensure the continuing safe storage of controlled drugs. The inspector observed a staff member dispense medication to people in a safe and hygienic way. The staff member was also seen to be patient and supportive to people whilst dispensing the medication. Medicine Administration Records (MAR) checked were completed with staffs’ signatures and records indicated that the medication had been given at the correct time. A recommendation was made to ensure that where handwritten entries of medication are needed that two staff check and sign to confirm that the dosage and administration of medication recorded is correct. Previous requirements relating to medication storage and records were checked and had been met. We saw low levels of staff on duty and the very high dependency needs of some people who live at Chapel View. Staff were seen to be very busy with only limited amount of time to spend with each person. Despite these problems staff spoke to people in a respectful way and showed empathy and patience when providing personal care to people. We would really wish to commend staff for the way in which they provided care to people at the home even within the limited staffing levels. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People were able to make some choices about daily living and be involved in some social activities. The home had an open visiting policy, which assisted in maintaining good relationships with people’s representatives. Meals served at the home were of a good quality and offered choice to ensure people receive a balanced diet. However, the meals and drinks were not served at times convenient to some people. EVIDENCE: Some people were able to spend their day as they wished and move freely around the home. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 14 People said that they were able to maintain contact with their family and friends. Relatives said that they were always made to feel welcome when they visited and they were able to visit at any reasonable time of the day or evening. Other people’s ability to express their choices was limited due to their immobility and communication difficulties. We saw that people received varying amounts of staff interaction and stimulation. It was concerning to see that at least 6 people at the home only received contact from people when staff were providing care. These people had no engagement with the world around them for long periods of time. They were only seen to have contact with staff at the times when care was being delivered. An activities coordinator is employed in the afternoon at Chapel View. A group of people were sat with her undertaking some craft activities and were laughing and seemed to be enjoying the group activity. However other people with mobility or communication difficulties were left out of the activity. The activities coordinator did say she would like more training on the benefits and types of one to one activities with people, if for example the person was being nursed in bed. These could be as simple as hand massage/pampering type activities or even reading a daily paper together. Relatives and staff themselves were concerned that there was not enough stimulation for people in the home and they said that this was due to the lack of staff. A more individualised activity programme is needed which should encompass the likes and dislikes of people, this information could be discussed with the person, relatives and the person’s key worker. This would enable people opportunity to exercise their choice in relation to social and leisure activities. People were rising and having breakfast at various times in the morning. However because a good number of people needed assistance from staff, problems were arising. The staffing levels were insufficient to facilitate the personal care assistance and the help needed to assist people with their breakfast. Several people were seen to eat their breakfast at 11am.Another person was shouting for help, as by 11:00 am they still had not received a drink or their breakfast. It was of concern to also here during discussions with two people that neither had been given a drink since they rose from bed .One person said they had to wait 3 hours and another person 4 hours. Other people said they do not always get a hot drink when they wake up because staff are too busy. They had to wait until breakfast is served 1-2 hours later. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 15 The delay in breakfast being served could mean that some people have 3 meals in 6 hrs and would not have another cooked meal for possibly 18 hours, which is clearly unacceptable. People said that they had a choice of food and that the quality of food served was generally good. Staff sat with some people assisting them to eat. This assistance was provided at a relaxed pace. (Previous requirement met). Chapel View Nursing Home DS0000006474.V337505.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 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a complaints procedure that people had access to and on the whole felt confident using. People were protected from abuse and had their rights protected. EVIDENCE: The complaints procedure was displayed in the entrance hall. This meant people had access to information about how to make a complaint and who would deal with it. The manager maintained a record of complaints. People and their relatives said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The AQAA confirmed there were policies/procedures/codes of practice in place to protect people from abuse. It also stated staff were trained in abuse and encouraged to come forward if they were concerned. A staff-training programme was in place for adult safeguarding training. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 17 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, 22 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The home was clean but not maintained to an adequate enough standard in all areas to provide a comfortable home for people. EVIDENCE: The building was clean and free from offensive odours. Many areas of the home, however, were untidy. Odd slippers were left in bathrooms. Slings used on the hoists were left piled on chairs. One bedroom carpet was stained and the bedside cabinet was splattered with food debris. Equipment was still being stored in bathrooms and in the baths making the room unusable. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 18 The lounge carpet had several cigarette burns on it. Generally many areas of the home such as the corridors, bedrooms and bathrooms are showing signs of wear and tear and will need refurbishing in the near future. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were not employed in sufficient numbers to fully meet peoples needs. Recruitment procedures promoted the protection of people and staff had completed training, including induction. EVIDENCE: The manager stated that on the day of the site visit a care assistant was off sick and she had not managed to replace them. We saw evidence via observation; care records and the AQAA that the dependency needs of at least 7 of the 34 people at Chapel View were very high. These people needed full assistance with all aspects of personal care and required high levels of nursing input. The shortfall of staff was clear to see during the inspection. The staff on duty, to their credit, were working hard, and as mentioned earlier were patient and showing empathy to people. However physically they could not provide care to people when people needed it, hence the reason why some people were eating breakfast after 11.00am and some people were left in isolation for long periods of time. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 20 Low staffing levels had been raised as an issue by staff at team meetings, minutes of these meetings were seen. Staff also said that the time they had to spend with people was inadequate. Discussions with staff and the manager identified that the dependency of people was high, however, current staffing level arrangements were calculated using the number of people and not their dependency. Staff on the day of our visit said that they were concerned that the staffing numbers were insufficient to meet the people’s needs. Staff made comments such as” we want to provide better care we just haven’t got time”. Relatives interviewed and via surveys also expressed concern over the staffing levels at Chapel View. Relatives made comments such as “the staff are lovely and try but people need more individual attention, they always have to wait for any help they need”. People said “the staff are so so busy I feel for them” Staff were so busy that we did not have the opportunity to speak with them in depth until the end of their shift. Additional staff are needed but also a review of the working patterns may be needed. Our evidence suggests that additional staff should be rostered to work at peak periods. Three staff files were checked. The files contained a range of information including two references and a declaration of health and identification. The staff had undertaken a criminal record bureau check (CRB), at the enhanced level. Staff spoken with were able to talk about the various training that they had attended. Development and training records were checked and discussed with staff. These showed what qualifications staff had achieved for example a number of staff approximately 80 had achieved National Vocational Qualification level 2 in care (NVQ). These records also showed when staff had completed mandatory training and refresher training. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The procedures and ethos of the home ensure that the home is run in the best interests of people who use the service. The homes procedures promote the health, safety and welfare of people who use the service and the staff. EVIDENCE: The manager is a qualified nurse and very experienced in the care of older people. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 22 Information from surveys and interviews confirmed that people and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. The home had a quality assurance system. Staff meetings were held and minutes of these meetings were seen. The manager said questionnaires were regularly sent out to relatives and people who live at Chapel View. However, results of these surveys had not yet been published. The area manager continued to carry out monitoring visits, and complete regulation 26 reports. These state what she found during her visit and who she spoke to. These were available at the home. Following this visit the company and manager must be aware of the need to promptly action requirements and ensure changes made are monitored and quality improvements sustained .A plan should be submitted to the CSCI detailing the proposed improvements. The home handles money on behalf of some people. Records were checked for three people. Account sheets were kept; receipts were seen for all transactions. Formal staff supervision, to develop, inform and support staff took place. The manager, however, said that this was not at regular intervals. Staff said they had received recent fire safety and other health and safety training .A sample of records showed that staff were receiving this statutory training. Fire records stated that weekly testing of the fire alarm system had occurred. A sample of records showed servicing of the homes utility systems had occurred. We found fire exits were clear and window restraints were in situ at first floor windows checked to prevent falls. Hazardous products were safely stored in the home. This will promote the safety and welfare of the people. Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 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 12,15 Requirement The persons daily notes must reflect the information actually recorded in the persons care plan. Care plans must contain more detailed information regarding the social care needs of people and be more person centred. Reviews of the care plans must include the wishes and opinions of people or their advocates. Staff must keep up to date records of any nursing provided to people, including a record of their condition and any treatment. People must have the opportunity to exercise their choice in relation to social and leisure activities. So as to minimise the risk of social isolation. People must receive meals and drinks at a time convenient to them. A programme of renewal of the fabric and decoration must be produced, and work started to implement the plan. DS0000006474.V337505.R01.S.doc Timescale for action 01/03/08 2. OP7 12,15 01/05/08 3. 4. OP7 OP8 12,15 15,17 01/05/08 01/03/08 5. OP12 16 01/04/08 7. 8. OP15 OP19 16 23 01/03/08 01/12/08 Chapel View Nursing Home Version 5.2 Page 25 9. OP27 18 At all times suitably qualified, competent and experienced people must be working in the home in such numbers as are appropriate for the health and welfare of people living at the home. (Previous timescale of 31/09/05 not met) 01/05/08 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. Refer to Standard OP7 Good Practice Recommendations Where possible some care plan records should be condensed. This would make it easier for staff to use the care plan documentation and make it easier to monitor peoples changing needs. A larger or additional cupboard should be fitted to ensure the continuing safe storage of controlled drugs. Two staff should witness handwritten entries on medication administration records. Equipment should be appropriately and safely stored. (Previous timescale of 31/12/05 not met) A review of the quality of care and the service provided should be undertaken in consultation with people and their representatives and a copy of the findings of that report should be made available people. All staff should receive appropriate supervision at regular intervals. 2. 3. 4. 5. OP9 OP9 OP22 OP33 6. OP36 Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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 © 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 Chapel View Nursing Home DS0000006474.V337505.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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