Inspection on 24/01/06 for Church Farm Nursing Home

This inspection was carried out on 24th January 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Church Farm Nursing Home 16/05/07

Church Farm Nursing Home 22/01/07

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

CARE HOMES FOR OLDER PEOPLE Church Farm Nursing Home Church Lane Cotgrave Nottingham NG12 3HR Lead Inspector Gillian Adkin Unannounced Inspection 24th January 2006 09:30 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 Church Farm Nursing Home DS0000065731.V277511.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. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Church Farm Nursing Home Address Church Lane Cotgrave Nottingham NG12 3HR 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) 0115 989 4595 0115 989 4345 Church Farm Nursing Home Ltd Mr John Spollin Mr John Spollin Care Home 34 Category(ies) of Dementia (34) registration, with number of places Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories Dementia - Over 65 years of age ( DE(E) ) (34) Dementia - 55 years and over (DE) ( 34) John Spollin will be the Responsible Individual only until the application of the person, who is named in the notice of proposal to register dated 27 October 2005 has been processed by the CSCI 2. Date of last inspection Brief Description of the Service: Church Farm nursing home cares for 34 residents in an extended and converted period building in the heart of Cotgrave. It is close to the village amenities and bus routes to the Nottingham city centre. The home is registered to provide nursing and non-nursing care. A maximum of three people who require palliative care can also be accommodated. There are both single and shared bedrooms. Two of the three bathrooms have adaptations. The home has an attractive garden to the front and an enclosed courtyard to the side which is level and is freely used by residents. All areas of the home are accessible through ramps and a passenger lift. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected against the Regulations, as in the Care Standards Act 2000.This was the first inspection for the new owners. This was an unannounced inspection, which took place over one day and commenced at 09.30 am on 24/01/06.The inspection took 7.5 hours. The Acting care manager and deputy manager facilitated the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. During this inspection a tour of the accommodation occupied by those case tracked took place along with other areas of the home as deemed necessary and the inspector viewed internal records, and care plans. The inspector spoke to residents, nurses, care and ancillary staff, and the General Practitioner for the home. A number of relatives were available during this inspection for comments. Additionally discussion took place with a student nurse regarding the care being provided to residents who were case tracked. There were 32 residents accommodated at the time of this inspection of which most had been assessed as having medium /high dependency needs. Conversation with all of the service users tracked was limited due to communication difficulties, however other comments were received about the service which are detailed below Typical comments included: “I do not have a lock on my drawer in my bedroom” “We always offer choices of food on a daily basis” “I feel part of my husbands life still, its very important for me and him to be able to visit when I like” Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 6 “Communication is very good in the home I would recommend the home to others” “I am not sure what the care plan says about XXX mobility” “I am so happy my relative is here I was able to go away at Christmas for the first time in years knowing she was safe and well looked after” “We are currently amending the Care plans “ “I have recently attended a Dementia Care Mapping course but have not as yet done any mapping” “We are decorating rooms as they become vacant” “I went on a two day induction course and have worked with more senior carers since” “We have a handover at the beginning of each shift” “ We rarely use agency staff” What the service does well: What has improved since the last inspection? Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 7 The home has developed a care planning policy, which is yet to be implemented. The system of quality assurance is being developed and evidence was seen of consultation with staff. All staff have been issued with copies of the GSCC code of Conduct. A staff member has completed the dementia care mapping course with the University of Bradford. Activities are being conducted throughout the day to include the most appropriate times for individuals. What they could do better: The assessment process for prospective residents must be reviewed to be more concise and more reflective of holistic needs and be based on person centred approaches. A review of assessment documentation would improve the assessment process. The registered person must ensure an accurate plan of care is implemented based on the assessment carried out by the home and in accordance with the Community Care assessment. This plan of care should clearly state how staff would meet individual service users needs including management of behaviour. Care plans must be reviewed at least monthly and be reflective of outcomes. Care planning documentation should be reflective of person centred care and care staff should be encouraged to read these documents regularly to ensure that information they have been given is accurate and up to date. Appropriate action must be taken to address poor moving and handling practises in the home. The registered person must accurately implement and update risk assessments in accordance to service users changing needs. Arrangements for the safe handling, recording and administration of medicines must be improved to ensure that residents remain safe. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 8 The registered person must respect service users privacy and dignity: Two way approved safety door locks must be fitted. Where considered inappropriate this must be reflected in care plans and demonstrate appropriate consultation with individuals concerned. The registered person must ensure all water temperatures are monitored and recorded and that records are available for inspection. To ensure the safety and protection of residents the registered provider must not employ staff to work in the home without all relevant documentation (CRB/POVA 1st checks, references, identification) being obtained and in place prior to employment commencing. The registered person must ensure all documentation is obtained in accordance with Schedule 2 of the Care Homes Regulations 2000. The registered person must ensure that nursing staff are clinically supervised, to identity shortfalls in practise and give staff the opportunity to speak about professional and other related issues with the manager. The registered person must without delay implement maintenance and decoration plan to ensure the home decoration is prioritised and maintained. It is recommended that a maintenance person be appointed to attend to ongoing maintenance issue. Nursing staff should ensure that all identified and holistic needs are included in care plans (including sensory needs). The method of administration and recording of refused medication must be improved to prevent errors occurring and ensure practise is within the Nursing and Midwifery Council Code of practise. The registered provider must ensure that the fire risk posed by the tumble drier is appropriately addressed and is fully described within a risk assessment detailing how the risk will be minimised. The homes’ fire risk assessment must be available for inspection. The registered provider should ensure that the environment provides the necessary equipment and facilities required by those with sensory difficulties or Dementia such as appropriate signs. Advice re the environment must be sought from an appropriate authority such as Trent Dementia Services Development Centre regarding good practise and current facilities provided. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 9 The registered provider must ensure that all incidents which affect the welfare of residents are reported the Commission for Social Care Inspection in accordance with Regulation 37 of the Care Standards act 2000. The home should develop a policy and procedure in relation to management of resident’s finances. 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. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 10 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 Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 11 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): 1.2.3.4. A review of assessment documentation would improve the assessment process and ensure that outcomes for service users are achieved. EVIDENCE: Relatives spoken with during this inspection confirmed that they had been given adequate information when their relative had been admitted. The home has a Service User Guide and Statement of Purpose, which were seen. It was acknowledged that many service users might not be able to read or understand this documentation due to the difficulties presented with their illness. The acting care manager (Director) stated that all service users admitted to the home have a written contract. Contracts were seen in two of the three files case tracked. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 12 Three service user files were inspected and case tracked. The current method of assessing individuals appeared to be fragmented in its approach and differed in all of the three care plans inspected. The acting care manager stated that a more formal and concise approach would be adopted to ensure that assessment of prospective persons was as accurate as possible. Staff spoken with were noted to refer to the yellow /green card in care plans for basic information which in one case was out of date. This system of gathering information is not considered to be appropriate or to meet good practise guidelines and could potentially lead to care needs not being fully planned for or understood by staff. Discussion with a member of staff who was at times required to undertake assessments identified that she was not fully conversant with documentation used. Due to lack of information gathered during assessment it was apparent that two staff were in one instance not fully aware of a service users needs. This has the potential to result in omissions in care. The assessment process for prospective residents must be reviewed to be more concise and more reflective of holistic needs and be based on person centred approaches. A review of assessment documentation would improve the outcomes for service users’. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 13 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): 7.8.9.10. Care plans do not fully describe how care needs are to be met by staff, additionally staff are not fully aware of care plan contents this has the potential for service users not having their individual / specialist needs met. Medication is not administered according to prescription this potentially puts residents at risk of harm. EVIDENCE: Three service users were case tracked and it was noted that although containing appropriate documentation regarding physical and mental health needs the plan of care did not clearly state how staff would meet individual service users needs including management of behaviour. Care plans had not in all three cases been reviewed monthly. One service user tracked who required dressings did not have a specific dressing care plan in place although it was indicated through discussion that a tissue viability nurse specialist had been consulted, Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 14 Daily records however were reflective of outcomes of care given. Care planning documentation was not fully reflective of person centred care and care staff spoken with although stating that they read the care plans were not fully aware of the contents and referred to the initial assessment card for information. Staff spoken with did not know what the current requirements were for an individual they were attempting to move. This resulted in a manoeuvre-taking place, which was considered unsafe and unnecessary for the service user. A senior member of staff witnessed this incident. Staff could not offer a reasonable explanation for their actions when moving the service user in a dining chair across the dining room. The service user was later observed mobilising with some help. The acting care manager stated that he had reviewed the care planning policy recently and that it was his intention to forms teams lead by a registered nurse who would have responsibility for reviewing plans. Discussions with the local General Practitioner indicated that he considered the home to fully meet the needs of individuals and that communication was excellent with the home. He further stated that service users medical needs are well managed by the home in collaboration with other professionals. A morning surgery was underway in the home on the day of inspection. This surgery occurs each week. The registered manager stated that he has conducted a mini survey with staff to establish where improvements in care could be made and it is intended that a code of Practise will be established. This is to be commended as good practise. Serious concerns were raised with the manager regarding the administration of medication, which the inspector observed a nurse dispensing into pots; this included an anti-psychotic medication, which was in a syringe. This does not meet with the NMC codes of practise and the Royal Pharmaceutical Sociey Guidelines for safe administration of medicines in Care Homes. It was indicated by other staff that this was common practise. This is considered to be poor and unsafe practise particularly when considering categories of registration. Further issues were identified around the recording practise when an inspection of medication relating to a service user tracked was found to be inaccurately dispensed/recorded. The staff were unable to give a reasonable explanation for the discrepancies. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 15 When spoken with over this matter the acting manager was unaware it was happening. An immediate requirement notice was left to address this practise. Relatives and a visiting General Practitioner confirmed that in their opinion the privacy and dignity of service users was maintained. All bedroom doors in the home are locked during the day this was described as being for the purpose of security and therefore would not reflect person centred care in terms of managing dignity on a person by person basis, furthermore no lockable facilities were provided in individual service users rooms for storage of private possessions. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 16 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): 12.14.15. Provision of good quality meals and significant effort into activities has resulted in resident’s individual requirements being met and a high level of satisfaction in terms of quality of life. This is considered a strength in the service provided. EVIDENCE: The Registered Provider and staff recognise the value of residents participating in enjoyable activities. Some of which are 1-1. Four part time Activities Co-ordinators are employed throughout the day and materials, equipment and resources are provided to support their work. Staff were working hard on the development of ‘Life Story Files’ which provide staff with an insight into the life of each individual. Relatives and friends are fully involved in this part of the assessment process. This is commended as good practise. The staff were observed interacting positively with residents and relatives throughout this inspection. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 17 Relatives when spoken with were very happy with the services provided. They stated that they were enabled to become involved in life at the home if they wished. Visitors stated that they felt welcome to visit at any without restriction. An excellent rapport exists between the General Practitioner and the home and a weekly surgery is held where patients are reviewed. Several examples of choice being offered were witnessed during this inspection including choice of seating at lunchtime. Staff spoken with stated that choice was discussed during induction. Meals and menus were inspected and appeared to be nutritious however it was noted that no second choice was detailed. It was strongly recommended when final menus are printed they include breakfast and evening meals and a second choice of midday meal. Discussions took place with the cook about how service users choose meals and alternatives available if their first choice is refused. The cook was fully aware of likes and dislikes and food preferences. Food served at lunchtime appeared to be hot, well presented, and appropriate to individual needs, staff when questioned were aware of difficulties associated with individuals and assistance required with their meals. A visitor was noted to be eating a meal with her relative, she stated she considered this important and enjoyed the experience, she was not charged for the meal by the home. This practise is to be commended. The home includes in their current fees the cost of alternative therapies and hairdressing. Therapists were observed in the home undertaking massage with one service user tracked. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 18 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 Complaints are taken seriously and relatives are confident in the process. Staff have a clear understanding of how to protect residents from abuse. EVIDENCE: The home works with Nottingham City Councils Multi Agency Policy in relation to adult protection. This was produced at inspection and referred to by staff. Discussion with care staff working in the home demonstrated that they were aware of how to manage incidents of alleged abuse. Ancillary staff spoken with were however unclear about the principles of whistle blowing and had not had any formal training, this is strongly recommended as a matter of good practise. The complaints procedure is fully detailed in the care plan and service user guide. Service users tracked were unable to confirm their awareness of this policy however relatives indicated that had seen the policy and considered that communication between them and management was sufficiently good to allow them to be confident in making a complaint. Church Farm Nursing Home DS0000065731.V277511.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 The home is warm, clean and reasonably maintained. Further refurbishment and decoration considering the individual needs of those with Dementia would enhance the living environment for them. Prioritising of decoration to service users bedrooms would ensure satisfaction with accommodation provided. EVIDENCE: New owners purchased the home in November 2006. Since this time some redecoration has been undertaken. Ongoing maintenance and refurbishment is required in some areas, which has been identified by the new owner. Rooms inspected were of a reasonable standard and adequately decorated although minor repairs to plasterwork were identified in one room. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 20 No odours were noted in the home. Discussion took place with the acting care manager regarding the necessity to ensure that the environment is appropriate to meeting the needs of those persons accommodated i.e. with Dementia. The acting care manager stated that he had given some consideration to painting doors in vivid colours to prevent confusion It was recommended that information be sought regarding improving the environment from an appropriate source such as the Alzheimer’s Society or Trent DSDC. No plan of maintenance has been developed to date and the home does not have a permanent maintenance person currently employed. The registered provider stated that they were about to advertise the post. The homes exterior is safe and secure and easily accessible to persons accommodated. On this occasion the laundry was inspected, it is sited away from the main areas of the home but is attached to one service users room. The home has two washing machines with sluice washes and a tumble dryer. Hand washing facilities are provided. Staff when questioned including ancillary staff stated they were aware of basic infection control procedures and care staff had received infection control training. Relatives spoken with indicated that the quality of laundry was very good. Church Farm Nursing Home DS0000065731.V277511.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): 27.29.30. An ongoing programme of induction and training is provided to ensure residents’ needs will be met. Residents are not fully protected from the risk of harm by the recruitment process, which requires strengthening. EVIDENCE: The inspector undertook a calculation of staffing hours and it was demonstrated that the home were meeting the recommended hours as in the Department of Health Residential Forum guidance. This calculation includes all of the managers rostered hours, although not identified on the roster the registered manager stated that some of these hours are supernumerary. Adequate numbers of hours are supplied for ancillary staff and the home are commended for the numbers of activities personnel employed. Relatives spoken with all stated that the home is always well staffed and service users needs are attended to in a timely manner. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 22 Three staff files were inspected and one file contained no CRB.POVA 1st check or any written references. No evidence was found to demonstrate that an interview had taken place. The administrator confirmed that a CRB had been applied for but not received to date and that references had not been followed up. This practise potentially puts service users at risk. Sufficient evidence was found in staff files to demonstrate that training supplied was appropriate and readily available to staff. The deputy manager had completed a Dementia Care mapping course recently. External training providers are used for new staff induction, this was fully discussed with a new member of staff. The deputy manager is a trained moving and handling trainer and all new staff are provided with MH training at commencement of induction. Church Farm Nursing Home DS0000065731.V277511.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): 33.35.36.38. EVIDENCE: Inspection of fire records took place and it was noted that two weekly drills and annual training takes place for staff. Discussion with the deputy manager indicated that a number of night staff had not undertaken this training recently and this must be completed within two months. Water temperature records and risk assessments for the building were not available for inspection due to the manager having to leave the home suddenly, these must be made available for inspection at all times. Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 24 Concerns were raised regarding the tumble drier which it was indicated could overheat and it was not clear if the risks had been assessed in a risk assessment. Concens were sufficient to require that an immediate requirement notice be issued. An example of poor practise was witnessed regarding the moving and handling of one tracked service user. Staff were unaware of the moving and handling requirements of the individual concerned and were not working with the information contained in the care plan. The acting care manager stated that the home are not responsible for the management of service users personal money. No policy has been developed for management of service user finances and this was recommended. Discussion with staff indicated that they were regularly supervised by nursing staff; this was evidenced in internal records inspected. No formal Quality Assurance policy or system is currently in place however discussion with the acting care manager and relatives indicated that regular informal discussion between them takes place , this was supported by the General Practitioner who discussed the quality of like experienced by his patients. It was recommended that a more formal approach to quality assurance is adopted. Church Farm Nursing Home DS0000065731.V277511.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 3 3 2 2 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 4 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 2 3 STAFFING Standard No Score 27 3 28 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 3 2 1 Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? 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 Requirement A full assessment of which prospective service users and or their representative have been party to be undertaken by people trained to do so. (This requirement remains unmet from the previous inspection) Timescale for action 24/01/06 2 OP38 OP8OP7 12.13.15 This requirement remains unmet from the previous inspection) 24/01/06 Where service users are assessed as being at risk from falls this is to be risk assessed to ensure the health and safety of the service user. Risk assessments are to be regularly evaluated to determines patterns of occurrence. This requirement remains unmet from the previous inspection) The care plans must be written to identify the action staff must take to manage episodes of aggression displayed by residents. This requirement remains unmet from the previous inspection) 3 OP8OP7 12.13.15 24/01/06 Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 27 4 OP9 13 5 OP29 19 Schedule 2 Arrangements for the safe 24/01/06 handling, recording and administration of medicines must be improved to ensure that residents remain safe and that trained staff are working within codes of practise and company policy. To ensure the safety and 24/01/06 protection of residents the registered provider must not employ staff to work in the home without all relevant documentation (CRB/POVA 1st checks, references, identification) being obtained and in place prior to employment commencing. The registered person must ensure all documentation is obtained in accordance with Schedule 2 of the Care Homes Regulations 2000 6 OP38 13(4) The registered provider must 24/01/06 ensure that the fire risk posed by the tumble drier is appropriately addressed and is fully described within a risk assessment detailing how the risk will be minimised. The homes’ fire risk assessment must be available for inspection. 7 OP8OP7 13,12(1) b 8 OP3 14 The registered provider must produce risk assessments detailing the management of behaviour,these must be reflected upon and evaluated at least monthly or as need determines. The assessment process for prospective residents must be reviewed to be more concise and more reflective of holistic needs based on person centred DS0000065731.V277511.R01.S.doc 28/02/06 28/02/06 Church Farm Nursing Home Version 5.1 Page 28 approaches. A review of assessment documentation would improve the assessment process. 9 OP7OP8 17(1) a.15 (2) Residents who require wound dressings must have a dressings plan put in place which is completed after each dressing takes place Care planning documentation should be reflective of person centred care and care staff should be encouraged to read these documents regularly to ensure that information they have been given is accurate and up to date in order to provide the type of care required by residents with Dementia. 28/02/06 10 OP4OP7 12.15.18 28/02/06 11 OP15 16 12 OP24 23 The registered provider must 28/02/06 when considering the categories of resident accomodated consider individual needs and requirements when deciding upon mealtimes and any new arrangements to be made. The registered person must 28/02/06 respect service users privacy and dignity: Two way approved safety door locks must be fitted. Where considered inappropriate this must be reflected in care plans and demonstrate appropriate consultation with individuals concerned. Lockable faclities must be provided in all bedrooms unless by agreement with relevant parties it is considered unecessary.Agreements reached must be fully documented. Water temperature recordings must be made avalaible for inspection. DS0000065731.V277511.R01.S.doc 13 OP24 23 28/02/06 14 OP25 13 28/02/06 Church Farm Nursing Home Version 5.1 Page 29 15 OP38 37 16 OP38 13 17 OP30 2 18(1) I, 18 OP19 23 All incidents affecting the health ,welfare and well being of residents must be reported to the Commission for Social Care Inspection without delay. The current moving and handling procedures must be reviewed and poor practise appropriately dealt with. Care practises(moving and handling) must supported by robust induction,and supervsion of staff at regular intervals. Where poor practises are identified appropriate action must be taken to address. The registered person must without delay implement a maintenance and decoration plan to ensure the home remains adequately decorated and maintained. It is recommended that a maintenance person be appointed to attend to ongoing maintenance issue. The registered provider should ensure that the environment provides the necessary equipment and facilities required by those with sensory difficulties or Dementia such as appropriate signs. Advice re the environment must be sought from an appropriate authority such as Trent Dementia Services Development Services regarding good practise and current facilities provided. 24/01/06 24/01/06 24/01/06 24/02/06 19 OP37 17 Records held on behalf of a residents (care plans etc) must be kept up to date and stored in accordance with the Data Protection Act 1998 Appropriate arrangements must DS0000065731.V277511.R01.S.doc 28/01/06 Church Farm Nursing Home Version 5.1 Page 30 be made to store records securely. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations It is recommended that the proforma document used for assessment is reviewed and improved to ensure that a robust/holistic assessment of a resident is undertaken before admission to demonstrate that the home can meet their individual needs It is recommended that care staff are given the opportunity to familiarise themselves with care plans on a regular basis and are informed of any changes to care plans in a timely manner. It is recommended that the current method of care planning is reviewed to ensure that all details required are fully described in relation to each identified need. I.e. one care plan per page. It is recommended that risk assessment training be provided for an appropriate person/persons. It is recommended that a separate dressings folder be implemented and used at each dressing change. Necessary documentation should be obtained from the Community Tissue Viability team. It is recommended that the medications policy be updated within the next three months. It is recommended that the practise of locking bedroom doors ceases and that where considered necessary on an individual basis this is formalised in the residents care plan in consultation with family/or representatives. It is recommended that POVA training be provided for ancillary staff. It is recommended that repairs to damaged plaster in Room identified takes place immediately. It is further recommended that consideration be given to the space afforded to medication trolleys and in relation to moving medication trolleys out of the room when required. It is recommended that ancillary staff be provided with infection control training. DS0000065731.V277511.R01.S.doc Version 5.1 Page 31 2 OP30 3 OP7 4 5 OP30 OP8 6 7 OP9 OP10 8 9 OP18 OP19 10 OP26 Church Farm Nursing Home 11 OP29 It is recommended that the application form currently used by the registered provider is reviewed and amended to ensure all essential information is provided by applicants prior to interview. It is recommended that formal supervision of staff takes place at least six times per year It is recommended that a fall/head injury protocol is developed to ensure that practise following an incident is consistent with recommended guidelines and is fully accountable. It is recommended that all remaining night staff who have not received fire training within the last six months receive this training within the next two months and six monthly as thereafter. It is recommended that a maintenance person be appointed to attend to ongoing maintenance issues. 12 13 OP36 OP38 14 OP38 15 OP19 Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Church Farm Nursing Home DS0000065731.V277511.R01.S.doc Version 5.1 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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