CARE HOMES FOR OLDER PEOPLE
Chorlton Place Nursing Home 290 Wilbraham Road Chorlton Manchester M16 8LT Lead Inspector
Geraldine Blow Key Unannounced Inspection 16th May 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 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. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Chorlton Place Nursing Home Address 290 Wilbraham Road Chorlton Manchester M16 8LT 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) 0161 882 0102 0161 860 6685 Southern Cross Healthcare Services Limited Veronica Amadi Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The maximum number of service users requiring nursing care shall be 45. The maximum number of service users requiring personal care only shall be 3. Registration is subject to compliance with the minimum nursing staffing levels indicated in the Notice previously served in accordance with Section 25 (3) of the Registered Homes Act 1984 issued on 3 June 2001. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 4th April 2006 4. Date of last inspection Brief Description of the Service: Chorlton Place Nursing Home provides accommodation for 48 older people. The home is registered to accommodate 45 older people assessed as requiring nursing care and 3 older people assessed as requiring personal care only. The premises are owned by Nursing Home Properties (NHP) PLC and are leased to Southern Cross Healthcare Limited. The home is located in the Chorlton area of Manchester close to main public transport routes, local shops, public houses and other social and recreational amenities. Parking facilities are available to the front and rear of the property. The home is a three storey purpose-built building set in its own wellmaintained grounds. Bedroom accommodation for residents is provided on the first 2 floors and the third floor is used as office space, which includes the companys divisional offices. The home offers accommodation in 48 single, en-suite bedrooms. Each floor has 2 lounges, a dining room and 2 small seating areas. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This visit was unannounced and forms part of the overall inspection process, it was conducted by 2 inspectors and took place on Tuesday 16 May 2006. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS) and the requirements made at the inspection on 15 February 2006 and 4 April 2006. This inspection was also used to decide how often the home is to be visited to make sure that it meets the required standards. The Pharmacist Inspector has visited the home on several occasions due to concerns regarding medication and a number of requirements have been made. On the day of this inspection the Pharmacist Inspector also visited the home to undertake a further specialist pharmacist inspection. A number of serious concerns were identified and a separate letter has been sent to the responsible individual of the home. As part of the visit, time was spent talking with the manager, the project manager, a support manager, the operations manager, the residents who live in the home and a visitor to the home. Time was also spent talking to and observing how staff work and interact with the residents. Documents including staff and residents files, records and other relevant documentation were also examined and a tour of the premises was made. Prior to this inspection, additional inspections were carried out to follow up concerns about how the home managed medication. The company that owns the home sent an action plan to the Commission setting out how things would be addressed and although some of the requirements made for improvement had been addressed an inspection of the medication systems and procedures by the pharmacist inspector showed that further improvements need to be made in how medication is managed. If the home continues to fail to meet the requirements the CSCI may take action to make sure the home meets the regulations. The pre-inspection questionnaire was not received by CSCI before this inspection. The CSCI had not received any complaints or concerns about the home since the last inspection. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection?
Since the last inspection all 4 lounges in the home have had a new carpet fitted. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 7 Since the last inspection the qualified nurses had all had care planning training and plans were in place to review all the care plans to ensure that they reach the minimum standards. However, the review was not complete and some areas of concern were seen, these are detailed below. Since the last inspection the senior management of the company have worked with the Commission to try to improve the safety of medication handling at the home. Meetings have been attended at the Commission’s office and the Commission has received acceptable action plans. However some areas of concern were identified which are detailed below. The home had employed a part time activities coordinator and evidence was seen of regular activities that include bingo, card making, a party for the Queens birthday and residents in the garden making hanging baskets. On the day of inspection the activities co-ordinator had taken a resident to the local shops. Since the last inspection the operations manager had sent out quality surveys to the residents/relatives in order to gain their opinions of the home. At the time of inspection no replies had been received. What they could do better:
Although the plans of care were in the process of being reviewed and some improvements were seen they were still not meeting the required standard, for example, in one file inspected important care issues had not been put into the care plan and areas of concern that had been documented had not been followed up. These shortfalls have the potentional to put residents at risk. As stated above the systems and procedures for dealing with medicines still needed improvements to protect residents, for example nurses had signed for medication that had not been given and had given medication that had not been signed for. As required at the last inspection a check of staff training had been done and the home had a computerised list of the training undertaken. However, evidence could not be provide that all staff had attended the required training and no evidence could be found in the staff files inspected that staff had taken part in induction training. The staff files inspected did not contain all the required information, for example one file contained only one reference and the gaps in the staff members employment had not been discussed. The home had company policies and procedures relating to adult protection. However, the home did not have the local guidance and contact numbers for making a referral should an allegation of abuse be made. The manager said she had trained some staff in adult protection but in order to protect the residents living at the home the local adult protection procedure must be
Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 8 available to all staff and all staff must receive training on the actions to be taken in the event of an allegation of abuse. The home were carrying out fire alarm checks every week and evidence was seen of fire drills, however there were gaps in the weekly tests of the means of escape and the emergency lighting had not been checked on a monthly basis. This has the potential to put residents at risk. 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. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home undertakes an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: A pre-assessment form was in use, to ensure prospective residents are only admitted on the basis of a full assessment. The manger said that the assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. Following the pre-admission assessment the home confirmed in writing to the resident that the home was able/not able to meet their assessed needs. A copy of the letter was also sent to the care manager. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 11 For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. The home does not provide an intermediate care service Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 7, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service Each resident had an individual plan of care. However, some areas of the plan required improvements to ensure residents’ health, personal and social care needs are fully met. The systems and procedures for dealing with medicines needed some improvements to protect residents. EVIDENCE: A random sample of care plans were examined. Evidence was seen of ongoing work to improve the documentation of the care planning system and the project manager was in the process of auditing all of the care plans. Risk assessments had been included and evidence was seen that monthly reviews had taken place. It was encouraging to note that privacy and dignity was promoted within the plans of care. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 13 During an inspection of the care files some serious concerns were identified e.g. one daily information record had recorded “puree diet and thickened fluids continued”, also documented was “peg feed regime continued”. This information had not been incorporated anywhere within the plan of care or in the nutritional risk assessments. It was of further concern to note that written information indicated that monthly reviews had taken place but the above information had not been included in the review. In addition one plan of care stated “spenco mattress” in use but at a later date it was documented that the mattress in use was an ‘air mattress’. This information had not been included in the documented monthly reviews. It appears that reviews are recorded without a thorough re-assessment of need and support taking place. In order to ensure all appropriate care is given to residents the care plan must set out in detail the actions which need to be taken by staff and a thorough review must take place and the care plan be amended and updated as required. It was of concern that a number of ‘body mapping’ tools contained statements such as, “found a big bruise on her rt lower arm” and “discoloured areas” to a number of body areas. There was no evidence that these identified concerns had been carried over onto the residents care plan for further action. It was noted that when residents had been assessed as having a high Waterlow score, the plan of care did not always document which pressure relieving mattress was in use. In order to evidence that appropriate measures have been taken to address an identified need this information should be documented. There was limited evidence that the plan of care had been drawn up with the involvement of the resident/relative. The daily information records were found to be vague in places, for example “assisted when needed” and “all care maintained”. It is recommended that these contain more detail to accurately reflect the nursing care provided to residents. As already identified in this report the pharmacist inspector has made several additional visits to the home to inspect the medication procedures. A number of serious concerns have been identified which will be addressed directly to the responsible individual. The records of food provided to a resident by the home had improved. However, it was noted that when the resident’s family brought food into the home accurate records had not been maintained and it recorded entries such as, “fed by relatives”. The record of food provided to a resident must be in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 14 Residents were registered with local General Practitioners and had access to visiting healthcare professionals e.g., Dietician, Chiropody, Dentistry and Ophthalmology. This ensured residents were in receipt of appropriate health services necessary to support their health care needs. The requirement made at the last inspection that a record of pressure sores/ulcers must be kept along with details of their treatment and that referrals to other health care professionals must be signed and dated and followed up in a timely manner had been met The previous requirement that restraints such as bed rails must be risk assessed had been met. From observations made during the inspection and discussions with members of staff and residents it appeared that the nurses and care staff treated the residents with respect and dignity. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Activities were provided and residents were able to maintain contact with family and friends. Residents were able to exercise choice and control over their lives and the residents enjoy the meals that they choose. EVIDENCE: The home had recently employed a part-time activities co-ordinator and a client social profile was completed on each resident on admission to the home. The activities co-ordinator was not available on the day of inspection, as she had taken a resident to the local shops. However, the manager said that the activities co-ordinator regularly consulted the residents about their preferred activities. The home had a display board advertising daily activities and photographs of cakes that had been made by residents and photographs of a game of carpet bowls. In the main reception area a large board displayed photographs of a celebration party for the Queen’s birthday and some residents were in the garden making hanging baskets and a collection of hand made cards were also on display. An activities file was available for inspection, which contained details of various activities undertaken and a record of who
Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 16 attended the activities although it appeared that the records were not accurate and not regularly completed. The home had an open visiting policy and visitors could be received in the residents’ own room or any of the communal areas of the home. Residents and staff spoken to during the inspection confirmed this. From speaking to residents and staff it appeared that residents are able to exercise choice and control over their lives. Evidence was seen that residents are able to bring personal possessions into the home. Information regarding local advocacy services was held at the main reception and was available on request. The menus had been developed on a 4-week rota in accordance with residents’ likes and dislikes and appeared to offer a varied, wholesome and nutritious diet. A choice of meals were available at each meal time and the chef confirmed that if residents did not want any of the choices on the menu he would prepare something else of their choice. Residents’ comments were positive with regard to meals. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 17 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 the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The home has the systems and procedures in place that allow people to express their complaints/concerns. However, people are not fully protected, as all staff had not undertaken the relevant Protection of Vulnerable Adult (POVA) Training. EVIDENCE: The home had a complaint procedure, which was on display in the main reception. The CSCI had not received any complaints about the home since the last inspection. The manager kept a record of complaints, which included details of the investigation and staff statements. The home had corporate policies and procedures relevant to adult protection and had a copy of the Departments of Health (DOH) Guidance. However, the home’s polices advises the home to follow the local guidance in the event of an allegation of abuse but the manager did not have a copy the Manchester’s Multi-Agency Policy and Procedure for the protection of vulnerable adults from Abuse. The manager said that she has held some training sessions for staff on the actions to be taken in the event of an allegation of abuse. In order to protect the residents living at the home all staff must receive up to date training on the Protection of Vulnerable Adults which includes the action to be taken in the
Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 18 event of an allegation of abuse and the local guidance must be available within the home and made accessible to all staff. It was encouraging to note that the Whistle Blowing Policy was on display in the staff rest room. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 19 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 the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The premises generally were clean and comfortable for the residents living there. EVIDENCE: The premises were generally clean and tidy and since the last inspection all 4 lounges had been re-carpeted. The décor and furnishings were homely in nature but were beginning to show some signs of general ‘wear and tear’. Resident’s bedrooms were seen to be comfortable and personalised. During a tour of the building it was noted that the sluice doors on both the ground and first floor were left open. This poses a potentional risk to residents who may wonder into the sluice. The sluice doors must be kept locked when not in use.
Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 20 The laundry was situated away from residents living and eating areas. Soiled linen did not come into contact with food storage, preparation, cooking, serving or dining areas. The home had up to date Infection Control Guidance. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The number and deployment of staff appeared sufficient to meet the residents’ assessed needs. However, the home was unable to demonstrate that its staff had completed the required training to meet resident’s needs. The procedures for recruiting staff were not robust and must provide adequate safeguards to protect residents. EVIDENCE: On the day of the inspection the staffing numbers and skill mix appeared appropriate to meet the needs of the residents accommodated. A visitor spoken to during the inspection said sometimes staff sickness can cause staffing difficulties but staff seemed to get together and cover everything. The home employs 28 carers with 7 members of staff having successfully achieved NVQ level 2 and 7 members of staff in the process of applying to undertaken NVQ level 2 training. A recruitment policy was seen in the HR policies and procedures. A random sample of staff files were inspected. It was seen that CRB and POVA checks had been undertaken. It was noted in 1 file that the employment history
Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 22 demonstrated gaps in employment. It was not evidenced that this gap had been explored. It was a concern that another file only contained 1 reference and that was not from the last employer but from another employer. To ensure the safety of the residents all gaps in employment should be explored and the reasons documented and 2 written references must be obtained One staff file inspected had a part completed induction programme whilst the other files had no evidence of any induction. Some certificates were held on file and the home had a computerised spreadsheet of training attended, which included Food Hygiene, Medication, First Aid and Leg Ulcer Management training. However, staff did not have an individual training and development plan and it was not possible to check if all staff had attended all the required mandatory training. Evidence must be provide that all staff have undertaken the necessary training in order for the home to ensure that it provides suitably qualified, competent and experienced staff to ensure the health and welfare of the residents are met. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The home has the systems in place to monitor the service based on people’s views. Not all areas of the home were seen to promote the health, safety and welfare of the residents and staff. EVIDENCE: The manager is registered with CSCI and is responsible for this home only. Following the last inspection the operations manager has sent out surveys to residents/relatives to seek their views of the service provided. At the time of inspection no responses had been received. The recommendation made at the last inspection that comment cards/quality surveys are sent to visiting
Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 24 professionals in order to obtain their opinion of the service being delivered had not been met and has been reiterated in this report. The operations manager said that it was her intention to review all the responses and produce an action plan for the home based on the results. The recommendation made at the last inspection that care staff should receive formal supervision 6 times a year and that supervision should cover all aspects of practice, philosophy of care in the home and career developments needs had not been met and has been reiterated in this report. Evidence was seen that the systems in place did safeguard resident’s financial interests and secure facilities were provided for any money or valuables held on behalf of residents. The home had recently introduced a new logbook for fire safety checks. However, the home were also continuing to use the old book so records were being duplicated and there were gaps in the recordings in the new book. Both books made the system confusing. Fire alarm checks had been undertaken on a weekly basis but the emergency lighting was last checked on the 14/3/06 and the checks for the means of escape/fire doors were not dated so it was impossible to ascertain if they had been checked each week. The home had fire risk assessments, however they were dated 9/3/05 and therefore need updating. In order to protect the safety of residents’ evidence must be provided of weekly test of the means of escape and monthly tests of emergency lighting. Evidence was seen of regular fire drills, 15/3/06 was the last recorded drill and staff attending had personally signed. The maintenance logbook was seen, however, the safety checks had not been recorded since March 2006. For example, water temperature testing was last recorded in March 2006 and the wheelchair checks last recorded in February 2006. The manager told the inspectors this was because he was off sick. In order to protect the residents these safety checks must continue to be undertaken in his absence. Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 25 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 1 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 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 26 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 13 & 15 Requirement 1. A full audit of all care plans must be undertaken within the timeframe set. 2. Each resident must have an individual plan of care that sets out in detail the action which needs to be taken by care staff to ensure that all aspects of health, personal and social care needs of the residents are met. 3.The plan of care, where possible, must be drawn up with the involvement of the resident in a style accessible to the resident. Once agreed it must be signed for by the resident where applicable and/or a representative. (The previous time scale of 31/03/06 had not been met). The record of food provided to a resident must be in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition.
DS0000021637.V294269.R01.S.doc Timescale for action 30/06/06 2. OP8 12, 17 Sch 3 & 4 31/05/06 Chorlton Place Nursing Home Version 5.1 Page 27 3. OP9 13 (The previous time scale of 22/9/05 and 08/03/06 had not been met). • The Registered Person 16/05/06 must make arrangements for the recording, handling, safekeeping and safe administration of medicines • The registered person must ensure that all medication records are accurate • The registered person must ensure that all medication must be administered as prescribed • The registered person must ensure that the ordering system for medication must be reviewed so that safe levels of medication are in stock. • The registered person must ensure that any medication which as been prescribed without clear directions, confirmation of the prescribers’ intentions must be sought. (The previous time scale of 09/01/06 had not been met). • The registered person must ensure that records must be kept regarding medication dose changes The registered person must ensure that nurses administering medication must be assessed as competent to carry out this task The registered manager must ensure that
Version 5.1 Page 28 • • Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc registered nurses operate within NMC guidelines regarding medication. (The previous time scale of 09/01/06 had not been met). 4. OP18 13 In order to protect the residents living at the home: 1. All staff must receive training on the actions to be taken in the event of an allegation of abuse. (The previous time scale of 01/04/06 had not been met). 2. The local policy for the Protection of Vulnerable Adults from Abuse must be easily accessible to all staff at all times. In order to protect the health and safety of residents the sluice doors must be locked when not in use. Two written references must be obtained for each employee and one reference must be from their last employer. Evidence must be provided that all staff have undertaken the necessary training in order for the home to ensure that it provides suitably qualified, competent and experienced staff to ensure the health and welfare of the residents are met. The manager must develop an action plan for the home based on the feedback from the comment cards sent out. (The previous time scale of 08/05/06 had not been met). 9. OP38 13 & 23 To ensure the health and safety of residents and staff are protected at all times the
DS0000021637.V294269.R01.S.doc 30/07/06 5. OP26 13 16/05/06 6. OP29 17 Schedule 2 18 31/05/06 7. OP30 30/07/06 8. OP33 24 01/09/06 30/06/06 Chorlton Place Nursing Home Version 5.1 Page 29 responsible individual must ensure that: • Weekly test of means of escape are undertaken • Monthly tests of emergency lighting. • The annual fire risk assessment must be updated. • Risk assessments of safe working practices must be undertaken • The safety checks undertaken by the maintenance man must be continue to be undertaken in his absence. 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. 6. Refer to Standard OP7 OP8 OP9 OP12 OP29 OP30 Good Practice Recommendations 1. It is recommended that the daily report sheet contain more detail to accurately reflect the care provided over a 24-hour period. It is recommend that the plan of care documents which pressure-relieving mattress is in use. It is recommended that nurses sign handwritten entries on the MARs and have them countersigned for accuracy by a second nurse. It is recommended that an accurate record is kept of all activities undertaken and the residents that took part in the activities. Gaps in employment history should be explored and the explanation documented. Skills for Care have introduced new requirements for staff induction and training. It is recommended that the home take account of the new requirements and include them in their induction programme and that a record of induction is maintained.
DS0000021637.V294269.R01.S.doc Version 5.1 Page 30 Chorlton Place Nursing Home 7. OP33 It is recommended that the comment cards are sent to visiting professionals and not just relatives in order to obtain their opinion of the service being delivered. It is recommended that staff receive formal supervision 6 times a year. Supervision should cover: All aspects of practise Philosophy of care in the home Career developments needs 8. OP36 Chorlton Place Nursing Home DS0000021637.V294269.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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