Inspection on 31/05/05 for Chapel View Nursing Home

This inspection was carried out on 31st May 2005.

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

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

Other inspections for this house

Chapel View Nursing Home 21/01/09

Chapel View Nursing Home 29/01/08

Chapel View Nursing Home 12/09/06

Chapel View Nursing Home 12/10/05

Chapel View Nursing Home 04/03/05

Chapel View Nursing Home 06/05/04

Similar services:

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Snydale Care Home

Hawkhills

Larchfield Manor

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Chapel View Nursing Home Spark Lane Mapplewell Barnsley S75 6BN Lead Inspector Jayne White Unannounced 31 May 2005 07:45 am 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 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 J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Chapel View Nursing Home Address Spark Lane Mapplewell Barnsley S75 6BN 01226 388181 01226 380270 Not known Chapelfield View Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Lynda Jackson N Care Home with Nursing 39 Category(ies) of OP Old age - 39 registration, with number of places Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons accommodated shall be aged 60 years and above. 2. There are 19 beds registered for nursing (N) and 20 for personal care (PC). Date of last inspection 9 February 2005 Brief Description of the Service: Chapel View is a care home providing nursing and personal care and accommodatiom to thirty nine older people. The home is owned by Four Seasons Healthcare Limited. 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. The home has 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. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over seven and three quarter hours from 7:45 to 15:30. An inspection poster was placed in the entrance to inform visitors an inspection was taking place should they wish to speak to an inspector. Shirley Samuels, another inspector assisted Jayne White on the inspection. Opportunity was taken to make a partial tour of the premises, inspect a sample of records, observe care practices and talk to residents, relatives, another professional, the nurse in charge and staff. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to four of the staff on duty about their knowledge, skills and experiences of working at the home, seven of the thirty one residents about their views on aspects of living at the home and three relatives. The manager was on holiday, therefore, some standards were not inspected or partially inspected and some requirements have been reviewed after further guidance from CSCI. What the service does well: The home was clean and on the whole well maintained and the residents spoken with found the home comfortable. On the whole residents were given choices of how they would like to spend their day within the home and they were able to maintain contact with family and friends. Intervention from other healthcare professionals was sought as appropriate. A balanced diet was provided and served in a pleasant dining area. Comprehensive accounting systems were in place to safeguard residents’ finances although a correlation of those records with residents’ actual monies was unable to be carried out. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Contracts/terms and conditions for residents continue to require putting in place. Care plans required more detail to demonstrate the care provided to residents. Although some residents’ felt they were treated with respect and dignity there were others that felt some of the younger staff did not understand about them getting old. Dealing with staff issues and ensuring resident’s had sufficient monies should be managed in a more effective way than displaying notices that were inappropriate. Staffing levels needed to be reviewed as they were insufficient to meet residents’ needs including assistance with eating, that meals were served at appropriate times and drinks were served consistently between meals, that residents’ needs were attended to in a timely way by staff and staff had time to spend with residents’ and that residents’ are appropriately supervised. A more robust way of recording complaints could be in place and the investigation method and details need to be recorded. Action was required to ensure a more robust recruitment was in place, secure fitting of guards around radiators, appropriate storage of equipment and creams and medication. Staff were now receiving appropriate training, however, there was further work before all staff were up to date with training requirements. There are quality assurance systems in place but the outcomes of some of those quality assurance methods appear not to have been listened to carefully enough to demonstrate the home was run in the best interest of the residents’ and there was a level of dissatisfaction with the service particularly around staffing levels. Improvements were required with some of the records kept by the home and records containing personal information about residents’ were insecurely stored. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 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. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 & 3. Standard 6 is not applicable to the home. No contract/terms and conditions were in place for residents at the home. Residents had their needs assessed prior to admission and confirmation was provided that the home could meet their needs. EVIDENCE: The administrator stated as far as she was aware no contracts/terms and conditions were in place for residents. The file of a resident who had been recently admitted to the home identified they had their needs assessed prior to moving into the home and a letter to their advocate had confirmed their needs could be met. An assessment had not been obtained from the care manager of the placing authority. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, & 10 Residents’ had an individual plan of care, however, further work was required to ensure it identified and reported on the resident’s health, personal and social care needs in sufficient detail. A range of health care professionals visited the home to assist in maintaining the health care needs of residents and assistance was sought as appropriate. Some residents’ felt they were treated with respect and dignity, others felt some of the younger staff, however, did not understand about them getting old. Observation of notices that were displayed and some care practices did not demonstrate residents’ dignity was maintained. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 11 EVIDENCE: Two plans of care were briefly inspected. There was not enough detail in the daily report; for example, the care plan identified monitoring dietary and food intake. The daily report said good diet and fluids taken. Risk assessments contained insufficient information, for example, walking inside. No hazards were identified but the outcome was ‘to make sure zimmer frame to hand’. It was not clear the resident and/or advocate had contributed to the plan. Care plans were reviewed, however, discussions with one relative identified the plan was not always a reflection of the care provided as it was not reviewed as required. Residents that were spoken to confirmed that they were satisfied with the care they received. Staff could clearly state what assistance residents’ needed with their personal care and residents said staff offered this appropriately as and when needed. Observations during the inspection together with discussions with residents confirmed they had appointments with a range of healthcare professionals. Some of the residents’ spoken to said that staff were very good, kind and considerate and that their privacy and dignity was observed and their personal care needs were met. Some residents did comment that some of the younger staff were sometimes a little abrupt and one was able to clarify this by saying they didn’t understand about getting old. The inspector observed that on the whole residents were clean and appropriately dressed. One resident had dirty fingernails. There were two posters displayed that were inappropriate to residents and could be offensive to advocates of the residents. The inspector removed one of the notices on the day of the inspection. Recently the lift was out of order and one resident was relocated on a temporary basis in another room that was used by another resident (they were in hospital at the time). Continence aids were put outside residents’ bedroom doors, in readiness for dressing the residents’. There was a telephone in the home, located in the corridor outside the lounges for the residents to use. This could be transported to individual bedrooms if required as all have telephone points. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 On the whole residents were given choices of how they would like to spend their day within the home and they were able to maintain contact with family and friends. A balanced diet was provided and served in a pleasant dining area. Staffing levels were insufficient to ensure assistance with eating was provided appropriately, that breakfast was served at an appropriate time for all residents’ and that drinks were consistently served between meals at appropriate times. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 13 EVIDENCE: Residents described how they spent their days at the home. The inspectors observed on the day how this was different for each resident. This was confirmed in discussions with residents. One resident said the activity coordinator was good and did activities on both a group and individual basis. One resident described how they were able to continue with their religious needs. There was a storyboard with some of the residents’ memories of holidays and pictures displayed. Residents’ confirmed that staff helped them to maintain contact with their family/friends and that they could choose who to see and who not to see. The inspector observed breakfast and lunch. At breakfast residents’ were brought into the dining room as they got up. At lunchtime the tables were set appropriately at selected tables. Some residents were sat waiting half an hour before the meal was served. When the meal was served it was unhurried and residents’ were given sufficient time to eat, however, the practice of assisting residents’ to eat was not done on an individual basis. Previous discussions with staff identified they were aware this was not good practice. Comments made by residents’ about the meals included ‘they don’t get a lot of greens – usually carrots and peas, occasionally cabbage’, ‘ don’t do bad for food, choice and variety – staff know likes and dislikes’, ‘we don’t always get a drink between breakfast and lunch’, ‘two good cooks’ and ‘they don’t always get a supper drink’. The inspector saw menus and a good range of food was recorded, however, the menu on display in the inspector’s opinion was inappropriate and the meal served was not the same as the displayed menu. The inspectors were able to confirm the mid morning drink was not served until midday and some residents’ were observed to go to the dining room to ask for a drink. A number of residents’ were on special diets for health reasons. Drink thickener prescribed for one resident was used for two other residents. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 A copy of the complaints procedure was displayed in the entrance hall in the home. EVIDENCE: The home did have a complaints procedure that the inspector saw. It was displayed in the entrance hall of the home. The home did keep a record of complaints, however, these were written formal complaints. They were not numbered or in a bound book and therefore the system was open to abuse. Inspection of the record identified a number of complaints had been made in regard to the change of use of the smoke room/conservatory area although this had not yet happened. The record did not clearly identify that an investigation of their complaints had taken place, just the action that was to be taken by the home. Discussions with residents and advocates identified the home had not liaised with residents and their advocates; they had heard the information ‘through the grapevine’. In addition another complaint made by a relative was recorded. The relative described what had happened as an outcome to the complaint, however, this was not recorded in the record of complaints and the action to be taken had not yet happened. Discussions with residents and/or their advocates identified although no formal complaints had been made they had concerns with the staffing levels at the home and that insufficient staffing was provided to give them confidence care was provided as it should be. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 22, 24 & 26 The home was clean and on the whole well maintained and the residents spoken with found the home comfortable. Guards covering radiators to ensure the safety of residents were not all secure and were a safety hazard. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 16 EVIDENCE: There continued to be ongoing refurbishment in the lounge areas, however, there remained the refurbishment of the occasional tables. The grounds were tidy, safe, attractive and accessible. There were no CCTV cameras in the home. Guards covering radiators to ensure the safety of residents were not all secure and were a safety hazard. Residents had access to all parts of the home. Where there were steps, ramps and lifts had been installed. A recent notifiable incident reported to the CSCI identified the lift had been out of order. Discussions with staff and relatives identified this was not the first time this had happened. Residents’ had, had to stay in bed because appropriate equipment and furniture were not available upstairs. In addition, four residents’ required a hoist and these were resident on both floors. This meant the hoist had to be transported between floors when required, delaying the assistance by staff that was required. There was appropriate storage space for aids and equipment, however, it was noted bedsides were stored in toilet areas in bedrooms and a supply trolley in a bathroom area blocking the access to the toilet. All residents spoken to were happy with their bedrooms. Observations of bedrooms and discussions with residents confirmed residents were able to bring their own possessions with them. This in some cases resulted in an inadequate number of electrical sockets. The building was clean and free from offensive odours. Laundry facilities were sited away from all food preparation and storage areas. A sluicing disinfector was in place. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Discussions with residents’, relatives, staff and observations of staffing levels identified that these were not sufficient to meet the needs of residents’ and previous arrangements to identify minimum staffing levels are inadequate. The recruitment procedure was not sufficiently robust enough to protect the welfare of residents’. There was evidence of a staff training programme, however, there was further work before all staff were up to date with training requirements. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 18 EVIDENCE: Although on the day of the inspection minimum staffing levels were met comments made in regard to the level of staffing and staff included ‘don’t like it at this home – not enough staff. Need to wait a long time for help’, staff don’t have time to sit and talk’, ‘do not feel confident about the care provided as there is not enough staff to assist to the level required’, ‘staff very good’, ‘would do anything for you’, ‘staff kind and approachable – could do with more staff’, ‘staff very nice’, ‘all loveable’, ‘we can have a laugh’, ‘staff are very busy’ and ‘staff do their best with the staff they have but not enough to do what is needed’. Staff described supervision of lounge areas would involve if you were in that area walking through to check everything was alright. Notifiable incidents reported to the CSCI have noted that increased supervision of lounge is required to assist in reducing the number of falls. On a morning staff stated it is 11:00 before all residents are up and one resident was observed eating breakfast at that time and dinner is served at 12:30. Staffing levels have been raised as an issue by staff at team meetings and time spent with residents’ too short. Discussions with staff also identified the dependency of residents’ is high, however, current staffing level arrangements are calculated using the number of residents. Three had recently terminated their employment and agency staff was now being used. The staff rota was not clear and not adequate to identify who was on shift and in what capacity. Two staff files were inspected, one who was a trainee placed at the home by a training agency. The files did not demonstrate a thorough recruitment process had been followed as required by the regulations. The trainee was working at times as a member of staff on shift and there was no evidence a satisfactory CRB was in place or that a POVA first check had been completed. Inspection of a staff training file identified induction to National Training Organisation specification had been completed and the member of staff had, had fire and protection of vulnerable adults training. Application forms identified staff had received training in food hygiene, first aid and moving and handling but there was no documentary evidence that this had been confirmed by the home. Discussions with staff identified one had NVQ Level 2 in Care, infection control and health and safety. First aid and food hygiene needed updating. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36, 37 & 38 There are quality assurance systems in place but the outcomes do not wholly demonstrate the home was run in the best interest of the residents’ and there was a level of dissatisfaction with the service particularly around staffing levels. Comprehensive accounting systems were in place to safeguard residents’ finances although a correlation of those records with residents’ actual monies was unable to be carried out. Improvements were required with some of the records kept by the home and records containing personal information about residents’ were insecurely stored. On the whole the health, safety and welfare of both residents’ and staff were promoted and safeguarded. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 20 EVIDENCE: Aspects of quality assurance were checked including staff and resident meetings. Discussions with residents identified there had not been a residents’ meeting for some time. They said that sometimes the manager did go and see how things were but commented ‘they could have a more listening ear’. This feeling was corroborated by a relative who felt the manager wasn’t as proactive as they had been when first appointed. They also said an annual survey is carried out by the company but they don’t know what happens to this and would suggest it doesn’t ask deep enough questions to assess the quality of care provided although comments can be made. Staff meetings had identified inadequate staffing levels but also identified the company were reluctant to staff above minimum staffing levels. The inspection report was displayed in the entrance hall of the home. Regulation 26 visits had been completed and these had identified action areas to the CSCI. All personal allowances are paid into one account, with signatories being persons employed by Four Seasons. The account did not pay interest. Reconciliation of the account and float is completed monthly and a weekly transaction of monies spent by and deposited by each service user is kept together with receipts. There were safe facilities to store the float. Current CSCI guidance acknowledged this practice for payment of personal allowances and finances met the regulation. The inspectors checked a sample of the records that the home was required to keep. These have been commented upon throughout the report and where necessary requirements made. There were records that contained personal information of residents’ left in corridor areas. Safety posters were on display. When the building was checked no fire exits were blocked. There were instances of sudacrem and inhalers insecurely stored in bedroom areas. Measures were in place to ensure the security of the premises and prevent intruders and ensuring these practices were carried out had improved since the last inspection. Electrical and fire equipment displayed evidence of testing. Notifiable incidents were being reported as required by the regulations. Discussions with staff identified there had been no improvements in the staff facilities although minutes from the staff meeting identified this was being addressed. Appropriate moving and handling techniques were observed. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 1 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x 2 x 2 x 2 STAFFING Standard No Score 27 1 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x 2 x 3 x 2 2 Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 22 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 1 Regulation 5 Requirement To complete the Service User Guide by including the full information required. Previously required on all inspections since 1 April 2002. The service user guide must include the amount and method of payment of fees and the arrangements for the provision of free nursing care. Previous timescales of 30 November 2003 and 30 September 2004 not met. A contract/terms and conditions must be provided for each resident. Previous timescale of 30 April 2005 not met. The daily report must contain sufficient detail to describe how residents needs have been met. Arrangements must be made for the satisfactory recording, handling and safe administration of medicines received into the care home. Previous timescales of 30 September 2003 and 31 July 2004 not met. A system must be implemented J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc 2. 1 5 Timescale for action 30 June 2005 Not checked on this inspection. 30 June 2005 Not checked on this inspection. 31 July 2005 3. 2 5 4. 5. 7 9 15 13 31 July 2005 30 April 2005 Not checked on this inspection 30 April Page 23 6. 9 13 Chapel View Nursing Home Version 1.30 to identify which supplement drinks are for each different service user. 7. 10 12 8. 10 12 2005 Not checked on this inspection Documented discussions must be 30 held with every resident, where Setember possible, to obtain their views on 2005 how they are treated by care staff. Action must be taken to address the findings. Appropriate action must be 31 July taken to manage staff issues. 2005 Notices which are offensive to residents and/or advocates must not be displayed. Residents must not use other residents bedrooms. Continence aids must not be put outside residents rooms ready for use. Staff offering assistance in eating to residents must do this individually. Previous timescale of 30 April 2005 not met. Training must be provided to the cook to ensure liquidised meals are served in line with good practice guidelines and presented in a manner that is attractive in terms of texture, flavour and appearance. Drink thickener prescribed for one resident must not be used for another. The complaint record must include the investigation details. Contact details of the local adult protection officer, social services must be included within the homes procedure for adult protection.The home must obtain a copy of the local multi agency procedures for adult protection. Occasional tables must be restained or replaced. J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc 9. 10. 11. 10 10 15 12 12 12 31 July 2005 31 July 2005 30 September 2005 30 June 2005 Not checked on this inspection 31 July 2005 31 July 2005 30 April 2005 Not checked on this inspection 30 June 2005 Page 24 12. 15 12 13. 14. 15. 15 16 18 13 22 13 16. 19 16 Chapel View Nursing Home Version 1.30 17. 18. 19. 20. 19 22 22 23 13 12 & 13 13 & 23 23 Previous timescale of 30 September 2004 not met. Guards around radiators must be made secure. Another hoist must be purchased. Equipment must be appropriately and safely stored. Independent wheelchair users must be offered rooms of 12 square metres. Previous timescale of 31 July 2004 not met. Staffing levels must be reviewed to meet the needs of residents. The manager must not employ staff unless a thorough recruitment programme has been used and documentation is in place that meets the regulation. Previously required on all inspections since 1/4/02. A CRB check must be applied for, for the member of staff who commenced work prior to 1/4/02. The manager must ensure all staff are trained in infection control, health and safety and moving and handling. Previous timescales of 30 September 2003 & 31 July 2004 not met. All staff must received Food Hygiene training. A review of the quality of care and the service provided must be undertaken in consultation with residents and their representatives and a copy of the findings of that report must be supplied to them and the CSCI. 21. 22. 27 29 18 19 31 July 2005 31 July 2005 31 July 2005 30 April 2005 Not checked on this inspection 30 September 2005 31 July 2005 23. 29 19 24. 30 13 30 April 2005 Not checked on this inspection 30 June 2005 25. 26. 30 33 18 24 30 September 2005 31 December 2005 Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 25 27. 36 18 28. 29. 30. 31. 32. 33. 37 37 38 38 17 17 23 13 The manager must implement a formal supervision process that ensures staff are supervised at least six times a year. Previously required on all inspections since 1/4/02. Records as required by the regulations must be maintained, up to date and accurate. Records containing information about residents must be securely stored. Staff must be provided with facilities for the purpose of changing. Creams and inhalers must be securely stored in bedroom areas. 30 April 2005 Not checked on this inspection 31 July 2005 31 July 2005 31 March 2006 31 July 2005 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. 4. 5. Refer to Standard 3 15 16 19 24 Good Practice Recommendations Where residents are assessed and placed through care management arrangements a copy of that assessment is obtained. The menu for the day must be provided in an appropriate format and accurately reflect the meal on offer. A more robust way of recording complaints should be implemented. A contingency plan is put in place for if and when the lift is out of order. An audit should take place in all bedroom areas and where double sockets are not in place should be identified on the programme of maintenance so that when bedrooms are redecorated two double sockets are provided. The manager must ensure compliance with the Water Supply (Water Fittings) Regulations 1999. 6. 7. 8. 26 Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 26 9. Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chapel View Nursing Home J51 S6474 Chapel View V218766 31.05.05 UI Stage 4.doc Version 1.30 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!