Inspection on 13/06/07 for Chelwood Corner Nursing Home

This inspection was carried out on 13th June 2007.

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

Chelwood Corner Nursing Home 29/10/08

Chelwood Corner Nursing Home 30/10/07

Chelwood Corner Nursing Home 06/02/07

Chelwood Corner Nursing Home 21/06/06

Chelwood Corner Nursing Home 20/02/06

Chelwood Corner Nursing Home 19/07/05

Chelwood Corner Nursing Home 03/11/04

Chelwood Corner Nursing Home 29/04/04

Chelwood Corner Nursing Home 04/06/03

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

Thorndene

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Chelwood Corner Nursing Home Beaconsfield Road Nutley East Sussex TN22 3HJ Lead Inspector Niki Palmer Key Unannounced Inspection 13th June 2007 11:20 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 Chelwood Corner Nursing Home DS0000013973.V340147.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. Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chelwood Corner Nursing Home Address Beaconsfield Road Nutley East Sussex TN22 3HJ 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) 01825-740282 01825-740282 ccnh@hotmail.co.uk Mr Mehrad Foroudy Mrs Jennifer Ann Foroudy Mrs Jennifer Ann Foroudy Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (27) of places Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated at any one time is twenty seven (27) That the care home provides general nursing care to older people aged sixty five (65) or over on admission and can provide care to people with a physical disability From time to time the home may admit service users whose assessed needs can be met and who are under the age of sixty-five (65) at the time of admission. 6th February 2007 Date of last inspection Brief Description of the Service: Chelwood Corner is a privately owned large converted manor house, which offers nursing care. The home is located on the outskirts of the village of Nutley, East Sussex. There are no local amenities within easy access, or access to public transport except taxis, although car parking is available at the home. Chelwood Corner is set within its own grounds and is spread out over two floors, which are accessible by a passenger shaft lift. The home comprises of 22 single and two double bedrooms. Nine single bedrooms have en-suite facilities, which were approved previously under old regulations, however these facilities would not be approved with today’s standards. The home provides nursing care and support to residents who are both privately funded and those who are funded by Social Services. Additional costs are charged for hairdressing, chiropody, personal toiletries, escorted travel, clothing, some activities and newspapers. Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. A copy of the home’s most recent inspection report is available on request. Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Chelwood Corner Nursing Home will be referred to as ‘residents’. Following the serious concerns that were raised at the home’s last inspection on 6 February 2007, the CSCI held a Management Review Meeting. Due to the serious nature in which the Providers were in breach of the Regulations under section 25 of the Care Standards Act 2000, Statutory Enforcement Notices were issued to the home on 20 April 2007. The Providers were required to address the identified shortfalls in respect of the following: • • • • • The home’s pre-admission and care planning procedures The home’s medication practices The systems in place to safeguard residents from potential harm, neglect and abuse Health and safety matters in respect of the environment The home’s recruitment procedures The home was required to comply with these by no later than 01 June 2007. The Providers did not challenge the Notices. This unannounced inspection took place on Wednesday 13 June 2007 and was undertaken by two Inspectors. The inspection lasted approximately five hours. The purpose of this inspection was to inspect all of the key standards and monitor the home’s compliance with the Statutory Enforcement Notices. 24 residents were accommodated at the time of the inspection. To help gather evidence on how the home is performing, the Inspectors talked with a number of residents, their relatives and staff members on duty. Six care records were examined in some detail for the purpose of monitoring care. Other records and documentation inspected included: the home’s Statement of Purpose and Service Users’ Guide, medication practices and procedures, the provision of activities and food, quality assurance systems, complaints procedure and the systems in place to safeguard residents from harm, the recruitment of staff and the provision of relevant training. Most areas of the home were seen. Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 6 An Annual Quality Assurance Assessment (AQAA) was completed and returned by the Registered Manager of the home following the inspection. The purpose of the AQAA is to provide the CSCI with an accurate account of comprehensive information in respect of how care is provided. The information that was provided however was repetitive and failed to give a clear account of what is actually happening in practice (as was seen on the day of inspection). What the service does well: What has improved since the last inspection? The home has made some progress towards meeting requirements from the last inspection report and Statutory Enforcement Notices: The Registered Manager has revised and implemented a policy and procedure in order to ensure that no person is admitted to the home without having had a detailed assessment of their needs undertaken. All residents now have their own individual care records, which are discreetly stored in individual bedrooms. These are being shared with residents and their relatives. The home’s medication policies and procedures have been improved and all surplus and unused medicines are now disposed of through a licensed waste disposal company. The Registered Manager has attended Safeguarding Adults training and has updated the home’s policies and procedures accordingly. Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 7 The Providers have begun to invest in the refurbishment and modernisation of the overall environment: Most communal areas and some individual bedrooms have been redecorated Most communal areas have been re-carpeted All windows are in the process of being replaced with double-glazing Two en-suite facilities have been encased in order to improve and promote residents’ privacy and dignity - The roof and guttering have been improved Residents and their relatives have been consulted regarding additional monies that are charged on a monthly basis for toiletries. What they could do better: The Inspectors spoke in detail with the Registered Provider and Manager in respect of the home’s most recent Statutory Enforcement Notices and it is of serious concern to the CSCI that there are still some areas outstanding in relation to: • • • Care planning Risk assessments Recruitment procedures In addition, concerns were raised regarding the home’s management of clinical waste and how residents’ continence needs are met. These shortfalls fail to promote and make proper provision for the health and welfare of residents. Due to these failings and the failure of the Providers to identify and rectify key issues, further enforcement action must be considered. 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. Chelwood Corner Nursing Home DS0000013973.V340147.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 Chelwood Corner Nursing Home DS0000013973.V340147.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): 1, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient information is provided to prospective residents and their relatives in order to support their decision of where to live. The home’s pre-admission assessment procedures are improved. EVIDENCE: The Inspectors were provided with an updated copy of the home’s combined Statement of Purpose and Service Users’ Guide. There was evidence to show that this has been updated since the last inspection. This document provides the reader with the home’s aims and objectives and philosophy of care, facilities and services, details of the Registered Manager, staffing structure and overall service provision. Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 10 Some residents spoken with said that they had been informed about the home prior to admission from their respective relatives and/or Adult Social care Worker. The Registered Manager has revised and implemented a policy and procedure in order to ensure that no person is admitted to the home without having had a detailed assessment of their needs undertaken by a Registered General Nurse (RGN). Three residents have been admitted to the home since the last inspection. Following concerns that have been raised during previous inspections regarding the home’s pre-admission assessment procedures, all three care records for these persons were seen on the day of inspection. The information that had been recorded was variable, dependant upon which RGN had undertaken the assessment. Whilst two were noted to be reasonably detailed and clearly outline the residents’ primary nursing needs, it was not clear in one person’s assessment who the assessment had been undertaken by, where, or when; concerns that have been raised during previous inspections and more recently the Statutory Enforcement Notices. This requirement is therefore outstanding. Intermediate care is not provided. Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst some improvements have been noted in respect of the home’s care planning procedures, residents’ personal care need continue to be at risk of not being met due to care plans and risk assessments not being completed and reflecting actual current practice. Due to these failings, the health and wellbeing of residents cannot be fully protected. Medication procedures are improved. EVIDENCE: In response to the Statutory Enforcement Notices, the Registered Manager has reviewed the home’s care planning procedures and all RGN’s have attended training in care planning, risk assessment and pressure area care. All residents now have their own individual care records, which are discreetly stored in individual bedrooms. Six of these were seen on the day of inspection. Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 12 Whilst some improvements have been noted in respect of the home’s care planning systems and records, the detail within these was variable. Most contained clear guidance for staff to follow in respect of meeting individuals’ needs including eating and drinking, pressure area care and mobility (this is improved since the last inspection), it was noted that one person’s records had been dated January 2007, when in fact they had been written following the home’s reviewed care planning procedures in May 2007. The Registered Manager was reminded that no records should be altered in line with the Nursing and Midwifery Council’s Code of Conduct and Record Keeping. At least one of the residents living at the home has epilepsy. Albeit there were standardised guidelines in place to support nursing and care staff of what to do in the event of a seizure occurring, there was no description of how the person’s seizures presented or if they require any medical intervention for a prolonged seizure. It is required that a system is put in place to ensure that individual care plans provide nursing and care staff with clear details of the action that is to be taken to meet the personal and healthcare needs of residents. These must be accurately maintained, signed and dated. Despite all RGN’s attending specific risk assessment training, it was concerning to note that in at least two instances, risk assessments had not been completed within individual plans of care in order to support care staff in meeting individuals’ needs including: manual handling, bathing, mobility, pressure area care, the prevention of falls and nutritional screening; areas of concern that were identified in the Statutory Enforcement Notices. Furthermore, most residents living within the home are provided with bed rails. The purpose of this is to reduce the risk of falls from bed. Albeit that risk assessments for their use had been undertaken (in most instances) it was of concern to note that in at least instance, the use of bed rails increased the level of risk for this person, as they were attempting to climb over them in the night; consequently they were having frequent falls. It is required that a system is put in place to ensure that detailed risk assessments are undertaken for all residents. This must include the safe use of bed rails. Concerns were raised in respect of how the home manages residents’ continence needs. It was noted that are no continence assessments within individual care plans and no reference to the type and size of pads to be used for each person. It is required that all residents are suitably assessed. Copies of assessments must be available within individual plans of care. Despite the above mentioned concerns, there was clear written evidence in place to show that all care plans are being shared with residents and their relatives. This is improved since the last inspection. Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 13 In response to the Statutory Enforcement Notices, the Registered Manager has reviewed the home’s policies and procedures for the safe handling of medicines. In addition, all RGN’s have received additional training, which included medication management and auditing for nurses. The Manager has confirmed that refresher training and regular audits will be undertaken at frequent intervals. The home’s medication systems and records were viewed. All medicines are delivered to the home on a weekly basis from the GP surgery in pre-packed boxes, which are individually labelled. RGN’s are responsible for administering all medicines. A sample of records and medicines were spot-checked. All medicines are stored in a locked trolley that is taken around the home when medicines are administered. A medication round was observed and was noted to be appropriate. Oxygen is used for one person and the container is appropriately stored. It was noted however, that the tubing and mask were not attached to the cylinder. This was rectified at the time of the inspection. Following concerns that were raised at the last inspection, the Registered Manager has taken the appropriate action to ensure that all surplus and unused medicines are disposed of through a licensed waste disposal company. It was noted however that the de-neutering container is not totally tamper proof and no chemical de-neutering is said to be required by the waste disposal company. The Registered Manager has agreed to discuss this with the licensed company and ensure that the home’s policies and procedures reflect the requirements and the law. This has not been reflected as a requirement at this time, but will be followed up at the next inspection. Each of the residents spoken with said that staff treat them at all times with dignity and respect. This was evident on the day of the inspection. Each of the residents are addressed by their preferred term and have easy access to private areas within the home. Chelwood Corner Nursing Home DS0000013973.V340147.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): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A variety of daily activities are planned. Relatives and visitors are made to feel welcome at the home. The provision of food is good. EVIDENCE: A part-time activities coordinator was employed to work in the home approximately six months ago. The Inspectors had the opportunity to speak with her on the day of inspection. She confirmed that she has had the opportunity to ‘get to know’ the residents over the past few months, which has enabled her to facilitate a programme of regular activities based on individual needs and preferences. She is due to attend Reminiscence Therapy training provided by the local council and Creative Activities training facilitated by Age Concern in the very near future. It was pleasing to note that individuals’ hobbies, likes and interests are recorded within care plans. This is improved since the last inspection. A sing-along session was observed to take place on the afternoon of the inspection. Residents were positive about the provision of daily life and activities within the home. Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 15 A small number of visiting relatives were spoken with during the inspection. It was pleasing to note that feedback was generally positive. They commented that they are always made to feel welcome by the home and that they are encouraged to visit at anytime. The Registered Manager states with the returned AQAA and the home’s Statement of Purpose and Service Users’ Guide that all residents are assumed to have the capacity to make an informed decision and choice unless proved otherwise. It is also stated within the home’s literature that all care staff are aware that individuals’ capacity to make decisions may change daily. The home is working towards the application of the Mental Capacity Act. The progress and implementation of this will be followed up at the next inspection. The Manager and other staff spoken with confirmed that residents are offered choice whenever this is possible. For example, the clothes they would like to wear each day, the activities that they participate in (or not) and whether residents choose to go to the lounge during the day or stay in their bedrooms. The home employs two part-time cooks, one of which was spoken with on the day of the inspection. All meals are based on a four weekly rotating menu. This showed a range of meals that were well balanced with fresh vegetables and fruit. Residents were observed to enjoy the lunchtime meal, which was calm and unhurried. Residents’ comments include: “The food is very good here” “I have plenty to eat and if I don’t like the meal, I can have something else”. One visiting relative said that he had eaten at the home on several occasions and enjoyed it. Chelwood Corner Nursing Home DS0000013973.V340147.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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems in place to ensure that all complaints are dealt with appropriately and improved procedures to ensure that residents are protected from harm, neglect or abuse. EVIDENCE: The home has a detailed complaints procedure in place, which is included within the home’s combined Statement of Purpose and Service Users’ Guide. It gives clear guidance with regards to how a complaint can be made and how the complainant can expect it to be dealt with. No complaints have been received by either the home or the CSCI since the last inspection. In response to the last inspection and Statutory Enforcement Notices, the Registered Manager attended a Train the Trainers course in March 2007 in respect of Safeguarding Adults. She confirmed that an additional three senior members of staff will be attending further training provided by the local council in due course. Clear polices and procedures were seen on the day of inspection. No alerts have been raised since the last inspection. Chelwood Corner Nursing Home DS0000013973.V340147.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): 19, 20, 21 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A refurbishment programme has been established, which is gradually improving the overall environment. EVIDENCE: A tour of the premises was undertaken by one of the Inspectors with one of the Providers. Most areas were seen. Following the last inspection and Statutory Enforcement Notices, the Providers have begun to invest in and address the serious shortfalls that were raised in respect of refurbishment and modernisation of the overall environment: • • • Most communal areas and some individual bedrooms have been redecorated Most communal areas have been re-carpeted All windows are in the process of being replaced with double glazing DS0000013973.V340147.R01.S.doc Version 5.2 Page 18 Chelwood Corner Nursing Home • • Two en-suite facilities have been encased in order to improve and promote residents’ privacy and dignity The roof and guttering have been improved In addition, the Registered Providers have identified and provided the CSCI with a maintenance programme for other areas of the home to be improved. This includes: • • • • The balcony being enclosed in order to enable residents to use this area to look out over Ashdown Forest and the home’s grounds All en-suite facilities being encased All bedrooms to be redecorated A new window to be installed in room 10 in order to improve ventilation A new maintenance person has been employed by the home, who was spoken with on the day of inspection. He confirmed that he is responsible for ensuring that regular health and safety checks are undertaken. It is required that the maintenance programme for the ongoing improvements to the home is followed. Most areas of the home were noted to be clean on the day of inspection, with the exception of one person’s bedroom that smelled strongly of urine. This is a concern that has been raised during previous inspections. It is required that the strong smell of urine in this bedroom is eradicated. The seating in the main lounge is arranged to be facing inward and this does not allow residents to view the well-kept and attractive gardens. One person commented that they would prefer to look outwards but that was not possible. As the Providers are planning to enclose the balcony area in order to enable residents to look out over the forest, their progress in respect of this will be followed up at the next inspection. Chelwood Corner Nursing Home DS0000013973.V340147.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): 27, 28 and 29. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home’s poor recruitment procedures continue to place residents at potential risk. EVIDENCE: In addition to the Registered Manager, the home employs eight RGN’s, 10 care assistants, eight domestic staff, two cooks and a maintenance person. The home is approved by a University to employ four adaptation nurses from overseas, however no staff are currently undertaking this course at this time. Staffing rotas confirmed that there are usually three RGN’s and three carers on shift in the daytime and one RGN and carer at night. It was noted however, that the Registered Manager’s working hours are not included on the staffing rotas and it was therefore not possible to ascertain her availability. A requirement has been made in respect of this. Staff spoken with confirmed that they have attended a number of different training courses since the last inspection including: tissue viability, care planning and risk assessments, medication and equality and diversity. Following the last inspection and issuing of Statutory Enforcement Notices, the Registered Manager has revised the home’s policies and procedures for the recruitment and selection of staff and she has confirmed in writing to the CSCI Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 20 that all staff currently employed to work in the home have satisfactory checks in place. Only one person (the maintenance person) has been employed since this time. It was concerning to note that there were no recruitment checks in place for this person. The Registered Manager stated that as he was selfemployed, she did not think that this was necessary, despite him working unsupervised on a regular basis throughout the home. This requirement remains outstanding from the home’s previous three inspection reports. As no new care staff have been employed since the last inspection, it was not possible to ascertain what induction processes are in place, although the Manager did state that she has obtained a copy of the Skills for Care induction booklet. The Registered Manager was reminded of her responsibility to ensure that all new staff undertake a thorough induction. This will be followed up at the next inspection. Chelwood Corner Nursing Home DS0000013973.V340147.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): 31, 33, 35 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Albeit that the Registered Manager has the relevant experience and qualifications to manage the home, evidence gathered during this and previous inspections indicate that the home is not managed effectively and in the best interests of residents. EVIDENCE: One of the Providers of the home continues to be the Registered Manager of the home. She has been running the home for the past 20 years and is an RGN with a background in midwifery and neonate nursing. Concerns were raised at the last inspection regarding the home’s quality assurance and auditing systems. Albeit that verbal and written feedback is obtained from relatives and visiting health and social care professionals, it is of Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 22 concern that recent inspections have identified a number of serious omissions, errors and requirements, which the service should have identified themselves through their own effective quality assurance systems. The Inspectors spoke in detail with the Registered Provider and Manager in respect of the home’s most recent Statutory Enforcement Notices and it is of serious concern to the CSCI that these issues have not been complied with in relation to: • • • Care planning Risk assessments Recruitment procedures Due to these failings and the failure of the Providers to identify and rectify key issues, further enforcement action must be considered. Each month, £5 is added to the invoice, or deducted from residents’ monies, to pay for toiletries. It was pleasing to note that since the last inspection, the Providers have obtained the agreement of residents (where possible) and their relatives for this. Written agreements were seen within individual care records. On the day of inspection, due to the ongoing maintenance work and replacement of windows, it was noted that a fire exit had been obstructed with furniture. This was brought to the attention of staff, who rectified the matter immediately. Following the last inspection, concerns were raised regarding some clinical waste (continence pads) possibly being burned in the grounds of the home (a concern that was founded in 2004, which resulted in a warning letter being issued by the Environment Agency). The CSCI notified the Environment Agency of this claim who subsequently made contact with the Providers. The Providers stated that they store all used pads in a shed within the grounds, before they are collected by a waste disposal company on a two weekly basis. This area was seen on the day of inspection. The bins provided were overflowing and a large number of sacks were lying on the ground. The number of bins is not sufficient for the number of sacks that were stored. The contract with the waste management company shows that a certain number are collected fortnightly. The smell was offensive and was inconsistent with the number of days that the Provider said they had been stored for. As well as the odour, vermin and domestic animals would be able to access this area and potentially spread disease and infection. This raises serious concerns regarding the home’s systems that are in place for the storage, safe handling and disposal of clinical waste. Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 23 The Registered Provider must ensure that clinical waste is managed effectively. Clear policies and procedures regarding its production, storage and disposal must be implemented. Chelwood Corner Nursing Home DS0000013973.V340147.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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 Chelwood Corner Nursing Home DS0000013973.V340147.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 OP3 Regulation 14(1)(2) Requirement Timescale for action 30/09/07 2. OP7 OP8 3. OP7 OP8 4. OP7 That a system is put in place to ensure that all pre-admission assessment forms are signed and dated by the person undertaking the assessment. [Outstanding from last four inspection reports]. 15(1)(2) That a system is put in place to (a-d) ensure that individual care plans provide nursing and care staff with clear details of the action that is to be taken to meet the personal and healthcare needs of residents. These must be accurately maintained, signed and dated. [Outstanding from last three inspection reports]. 13(4)(a-c) That a system is put in place to ensure that detailed risk assessments are undertaken for all residents. This must include the safe use of bed rails. Staff must be aware of the action that they need to take in order to reduce any potential risks. [Outstanding from last two inspection reports]. 12(1)(a) That continence assessments are DS0000013973.V340147.R01.S.doc 30/09/07 30/09/07 30/09/07 Page 26 Chelwood Corner Nursing Home Version 5.2 OP8 5. OP19 (b) 23(2)(b) (d) 6. 7. 8. OP26 OP27 OP29 16(2)(k) 17(2) Sch 4 (7) 19 & Sch 2 undertaken for all residents in need. These must be included within individual plans of care. That the maintenance programme for the ongoing improvements to the home is followed within the given timescales. That the strong smell of urine in one bedroom is eradicated. That the Registered Manager’s working hours are clearly identified on the staffing rota. That no person is employed to work in the home without satisfactory recruitment checks including: A completed application form; Proof of identification; Two written references one of which must be from their previous employer; Receipt of a CRB/PoVA First check. Clear and accurate records must be maintained in respect of this and made available for inspection. [Outstanding from last two inspection reports]. That a robust quality assurance system is fully introduced to identify key areas which require action from the Providers and staff, to ensure all aspects of the home are managed well in order to meet the needs of residents. [Outstanding from last two inspection reports]. That clinical waste is managed effectively. Clear policies and procedures regarding its DS0000013973.V340147.R01.S.doc 30/09/07 30/09/07 30/09/07 30/09/07 9. OP33 24(1)(a) (b)(2)(3) 30/09/07 10. OP38 13(3) 30/09/07 Chelwood Corner Nursing Home Version 5.2 Page 27 production, storage and disposal must be implemented. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Chelwood Corner Nursing Home DS0000013973.V340147.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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