Inspection on 18/07/07 for Church View (Nursing Home) Limited

This inspection was carried out on 18th July 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

Church View (Nursing Home)... 19/08/09

Church View (Nursing Home)... 06/01/09

Church View (Nursing Home)... 15/07/08

Church View (Nursing Home)... 31/05/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Church View (Nursing Home) Limited Princess Street Accrington Lancashire BB5 1SP Lead Inspector Mrs Janet Proctor Unannounced Inspection 18th July 2007 09:30 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 View (Nursing Home) Limited DS0000066412.V340063.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. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church View (Nursing Home) Limited Address Princess Street Accrington Lancashire BB5 1SP 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) 01254 386658 Church View (Nursing Home) Limited Ann Wearing Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability (1), Physical disability of places over 65 years of age (24) Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include: Up to 24 service users in the category PD(E) requiring nursing care. One (1) named service user in the category PD requiring nursing care. 2. Up to 26 service users in the category of OP requiring nursing care. The care home should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 31st May 2006 Date of last inspection Brief Description of the Service: Church View Nursing Home was purpose built in 1990. The home is registered to provide 24 hour nursing and personal care for up to 40 residents. Accommodation is provided on 2 levels. The first floor comprising only four rooms and a lounge. All other accommodation and facilities are on the ground floor. This includes 2 lounges and a spacious dining room. All bedrooms are single occupancy with en-suite facilities. A stair lift provides access to the first floor. There are gardens and a car park for visitors and staff. The home is situated in a quiet residential area in Accrington close to local amenities. The current fees charged at Church View Nursing Home are £374-00 to £514.50 per week, depending on the type of care required. Additional charges are payable for hairdressing, newspapers and hospital visits. A copy of the statement of purpose and service user guide is available to prospective service users on request. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Church View Nursing Home on the 18th and 19th July 2007. No additional visits had been made since the previous inspection. On the day of the inspection there were 34 residents at the home. On the day of the inspection information was obtained from staff records, care records, and policies and procedures. Information was also got from talking to residents, the Manager, staff members and visitors. A tour of the building took place. Wherever possible the views of residents were obtained about their life at the home and their comments are included in the report. What the service does well: A thorough assessment was done before a resident came to live at Church View Nursing Home. The manager then had all the information she needed to make a decision about whether the home could meet the needs of the resident or not. Some of the care plans examined gave very good directions to staff on how to care for the resident. This meant that staff were aware of the individual and unique needs of the resident and knew how to meet these. Some of the care plans told staff how to ensure that residents received their care in private so that their privacy and dignity was respected. Residents spoken to praised the staff and said how well they were looked after. They said, “It’s very nice. Everybody’s very kind and if anyone says anything else they’re lying” and “I like it here. They’re all very nice and look after me well.” The senior staff ensured that GPs and other professionals were contacted when a resident was unwell or needed some treatment. They kept relatives informed so that they were aware if anything was wrong. A relative said, “He’s looked after very well. I’m kept informed of his condition. They always ring the Doctor when it’s needed.” Visitors could come to the home at anytime and were made welcome. A relative said, “I visit every day until 4.00 pm. They make me feel welcome and always give me drinks and on some days I have lunch.” Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 6 The routines in the home were flexible and residents had control over what they did and when. A resident said, “I’m in bed now because I had a bad night. If I have a bad night then I stay in bed the next day and rest. You can do that – nobody makes you get up.” The food served at the home ensured that a balanced diet was served and was to the liking to of the residents. They said, “The food’s very good” and “You get plenty to eat – I’m never hungry”. A high number of the care staff had the national Vocational Qualification in care. This meant that they had been given the skills and knowledge to be able to do their work. What has improved since the last inspection? What they could do better: All residents should receive a copy of their terms and conditions of residency at the time they move into the home. This is so that there is no potential for misunderstandings to occur about what will be provided. Prospective residents should receive confirmation in writing that their needs can be met at the home so that they can be confident that they will get the right care. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 7 The plan of care for each resident must identify all the needs and tell staff precisely how they should meet these. This is so that staff are aware of all the needs and give the right care in the same manner. The cupboard for storing Controlled Drugs must be large enough for all the drugs so that they are kept secure. The records of the Controlled Drugs kept at the home must be accurate. Medications should be disposed of as they are no longer needed so that they cannot be misused. Toiletries should not be left in bathrooms, this is to prevent them being used communally. There should be records of the activities done with each resident so that it can be shown that their social and recreational needs are being met. All required documents and details must be obtained before any new employee starts work so that it can be shown that they are suitable for the post. All new staff must receive a structured Induction training so that it can be shown that they have the basic skills and knowledge to do their work. A record should be made of all training given to staff so that it can be seen which staff have undertaken what training and when. A system for reviewing and improving the quality of care should be established and maintained so that issues requiring attention are identified and can be acted upon in a timely manner. The records of money held on behalf of residents should show the transactions and the balance. This is so that they can checked to ensure that the money held is correct and to explain where money had come from and gone to. All care staff should receive regular supervision to ensure that they work to a consistently high standard and can discuss any concerns that they may have. All electrical equipment should be tested annually to ensure that it is safe for residents and relatives to use. Bedside rails must not be used unless there has been a thorough risk assessment to show that they are in the best interests of the resident. This assessment must include the type of bed, mattress, and rails as well as the residents’ behaviour and condition, as injury can occur as a result of all these factors. Denture cleaner tablets must only be used following a risk assessment to show that the resident can use these safely and that they can not be accessed by other residents who may misuse them. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 8 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. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 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 Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was sufficient information to enable people to make a decision about the home. Contracts were not issued at the point of moving into the home, which had the potential for misunderstandings to occur. Residents received an assessment so that their needs were known before they came to live at the home. EVIDENCE: The Statement of Purpose and the Service User’s Guide had been revised so that they were current and accurate. A copy of the Statement of Purpose and Service User’s Guide were made available to prospective residents and relatives. Contracts for residents were in the process of being revised, as the current ones do not make it clear what was provided for the fees paid. There was no contract for two residents who had recently been admitted. All care home Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 11 providers must give people personalised information about the fees and terms and conditions of their stay, to include accommodation, food and personal care. The information must include the method of payment of the fees and the person or persons by whom the fees are payable. This information should be provided, ideally earlier, but at the latest by the day the person moves into the care home. An assessment was done before the resident came to stay at Church View. The pre-admissions assessment covered all the areas of care and were kept on file in the care plan. They were used to form the initial care plan on admission so that staff knew about the resident’s needs. Prospective residents did not receive a letter telling them whether their needs could be met at the home. This meant they could not be confident that they would receive the right care. Intermediate care was not given at Church View Nursing Home. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents had a plan of care, but there was not enough detail in all of these to ensure that their health, personal and social care needs were known to staff and could be met by them. Medication practices protected residents’ health. Privacy and dignity was respected. EVIDENCE: Each resident had an individual care plan. Three of these were examined in depth and two others viewed for particular issues that were identified during the inspection. Two of the care plans seen were extremely well written. They identified all of the residents’ needs and gave very detailed directions to staff on how these were to be met. They were very individual in the information that they gave about the residents. For example, about the use of make-up and communication for one lady. The plans were reviewed monthly. The review did not give an indication of whether the care that was being given to the resident was achieving the proposed aims. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 13 One of the residents whose plan was examined had only been in the home for a few days. A plan of care had been commenced but obvious issues had not been included, that is, catheter care and being an insulin dependent diabetic. A behavioural chart was in use for another resident. This included details of the incident, the action taken and the effectiveness of this. There were no details in his plan of care about his behaviour. The daily notes recorded episodes of being abusive and threatening but this was not identified as a problem, therefore there were no directions to staff on how to deal with or manage this. This could lead to inconsistency in how staff approached him. The accident records showed several for one particular resident who was having repeated falls. There was a falls risk assessment that showed she was at high risk of falls but the care plan did not identify this. Her plan had been reviewed at the end of June 2007 but did not take into account the fact that she had had 5 falls from the first of June to that date. Health assessments were done for the risk of falls, the risk of developing pressure sores, nutrition and moving and handling. This enabled potential problems to be identified and action to be taken on these. Residents had access to GPs, District Nurses and other health professionals as needed. The storage of the medications was secure. The temperature of the room had exceed 25 degrees on some days, which could affect the potency of the medication. There were good records to show what medication had been ordered and received at the home. The records of administration were clear and there were no unexplained gaps. Not all medications received mid-month and hand written on the chart had been witnessed. This meant there was the potential for errors to occur. There were records to show what medications had been destroyed at the home. These should be disposed of as they are no longer needed. The practice of collecting these up for some time before disposing of them puts them at risk of being mis-used. The Controlled Drug cupboard was too small for the amount of items being used at the home. Registers were kept of the Controlled Drugs. Not all of the balances of the liquid Controlled Drugs were correct. The Oramorph bottles were not dated on opening so it could not be determined when they should be disposed of. Staff were seen to approach residents in a nice and friendly manner. There were details in the care plans for staff to follow about how to maintain privacy and dignity. For example, “sometimes forgets to close the door – close it for him and explain what you are doing”. Toiletries were seen in a bathroom, which meant they could be used communally. Church View (Nursing Home) Limited DS0000066412.V340063.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. The increase in activities meant that social and recreational needs were being better met. The daily routines were flexible and meant that residents had choice and control over their lives. Residents received a balanced diet that was to their liking. EVIDENCE: There was an Activity co-ordinator who worked for four hours a day for four days a week. She had a range of activities that could be done e.g. arts and crafts, bingo, floor games, board games. She had used the information from the personal profiles of residents to plan what activities would most appeal to them. She said that she asked residents each day what they wanted to do. She did one to one sessions with residents who are reluctant to join in. She kept an activities log that showed the date, the activity, and the residents involved. This was not fully up to date. Visitors were welcomed into the home at anytime and offered refreshments. There were some details in the plans of care about routines and preferences. Residents and staff spoken to said that these are flexible. Residents could Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 15 make a decision about what time to get up and go to bed. They could use their bedrooms as they wished. There was a 3-weeks rota of menus. This did not show a choice at mealtimes although a choice was offered and was displayed on the notice board. A member of the kitchen staff asked residents each day what they would like for lunch and tea. Their choice was noted and also any alternatives requested One resident spoken to was vegetarian and confirmed that he received a correct diet for his needs. Night staff had access to food during the night so they could prepare snacks if anyone was hungry. Records were kept of the meals taken by residents and of storage and cooking temperatures. The meal served on the day of inspection looked appetising and was enjoyed by residents. Staff gave assistance in an unhurried manner. Those on liquidised diets had the items all blended together, which did not look attractive and appetising. Church View (Nursing Home) Limited DS0000066412.V340063.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. Residents had information about how to complain and were confident that these would be taken seriously and acted upon. Residents were protected by the procedures and training given to staff. EVIDENCE: There was a copy of the complaints procedure behind each bedroom door. This did not have the current address of the Commission, which may cause misunderstandings about how to contact us. There was a complaints log. No complaint had been received at the home since 21st June 2006. One complaint had been received by the Commission and sent to the manager for her to respond to under their own complaints procedure. This had not yet been completed. Residents and a relative spoken to said that they had no complaints about the home or the care. The procedure for safeguarding adults had been reviewed. This was written in an easy to understand manner and gave staff concise and essential information of what to do and who to contact. It included telephone numbers. There was also a Whistle-blowing policy that told staff that they had a duty to report any suspicions or incidents and gave them an external telephone number to contact if they wished to use this. Training in safeguarding adults had been done by some staff and others were booked to do this late July. Staff spoken to were aware of what to do if they saw, heard or suspected something was not right. Church View (Nursing Home) Limited DS0000066412.V340063.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were provided with a safe, clean and comfortable place to live. EVIDENCE: Some recent work had been done at the home in preparation for a new unit for people with dementia. There was no routine programme of maintenance although there was evidence that bedrooms were decorated as they became vacant. The premises were warm, clean, tidy and looked well maintained. The decor and furnishings were homely. Some residents had brought in items to personalise their bedroom and this made them look very homely. There was a Nurse call system with wander leads for those who couldn’t reach the wall point so they could call for staff if they needed them. Externally the gardens were overgrown. In particular some bedroom windows had bushes outside that were partially obscuring the view for the resident. Arrangements were being made for a gardener to come and do the grounds. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 18 There was a separate laundry. This had sufficient equipment for the laundry needs of residents. There was a sink with hand-wash, paper towels and plastic gloves so that staff were able to protect themselves from infection. There were infection control procedures for staff to refer to. Church View (Nursing Home) Limited DS0000066412.V340063.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, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient staff on duty to meet residents’ needs. Recruitment procedures were thorough enough to protect residents. Not all new staff had been provided with sufficient training to ensure they could competently undertake activities expected of them. EVIDENCE: There was a rota to show the name, designation and hours worked by each staff member. There was sufficient Registered Nurses, care staff and ancillary staff on duty each day. The Manager was supernumerary to these numbers. The files for three staff members were examined. These showed that an application form was completed that gave a full history of employment. The applicants had an interview with the manager before being offered the post. Two references were requested and a Criminal Records Bureau check done. A member of staff who was employed late last year confirmed that her recruitment had followed this procedure. Contracts were given to staff and a copy of the GSCC code of conduct and practice. One file did not have any proof of identity and one file had only one reference. For Registered Nurses the Manager asked to see the new PIN card but did not routinely check this with the Nurses and Midwifes Council. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 20 The staff files seen stated that a first day Induction had been done and evidence of this was seen. The skills for care 12 week induction programme had not been done with the new staff as they had gone straight onto National Vocational Qualification training. This meant that they had not been given an introduction to ‘basic’ knowledge that is deemed important to enable new staff to do their work. In working towards their National Vocational Qualification they may not receive this knowledge for some time. Training was being given to staff but there were no overall records to show which staff had done what training and when. Individual files seen showed that training in safe working topics had been done, or arranged, for most staff. Staff members spoken to said that they had received training and that they could ask if they felt that they needed more training or wanted to know about something in particular. There were 18 carers employed of which 12 had NVQ 2 or 3. Six other staff were on the course and there was a commitment to achieving 100 . Church View (Nursing Home) Limited DS0000066412.V340063.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, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was managed by a competent and capable person. There were no systems for monitoring the quality of care delivered at the home, which meant that it could not be shown that the service was being run in the best interests of the residents. Records of money held were not complete so it could not be shown whether these were correct or not. The health, safety and welfare of residents was not fully protected. EVIDENCE: The manager was now registered with the Commission. She is a Registered Nurse with management qualifications and has previous experience of managing a care home. She has a job description that gives her role and responsibilities. Staff spoken to said that they felt supported by the manager and could approach her if they had problems. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 22 The home had achieved the nationally accredited Investors in People award. There were no internal auditing systems to monitor the quality of the service and help improve outcomes for residents. An annual development plan to help focus aims for the next 12 months was not available. Resident’s and their relatives were encouraged to give feedback about the care provided at the home at anytime and a residents and relatives meeting had been held to obtain their views. However, there were no other formal systems for obtaining the views of residents and their relatives in place. The manager held staff meetings with the different grades as and when needed. Any money held for residents was in a secure place. There were no proper records of the cash kept in the home. There were separate purses for each resident with their money in, but no indication where this had come from and what the balance should be. Therefore, these could not be checked properly and it could not be determined if the amount held was correct or not. Receipts were given for any cash or valuables handed over for safe -keeping. Discussion with two members of staff confirmed that appraisals had taken place annually. However, formal supervision was not yet being done with the care staff. All fire safety equipment was checked and serviced regularly. The gas and electrical systems had been checked. The Portable Appliance Testing was overdue. The bath lifts and the hoists had been serviced every 6 months as required. There were health and safety policies and procedures. Accident records were kept and notifications sent to the Commission of any issues affecting the health and welfare of residents. A number of residents used bedside rails. There was a risk assessment but this did not look at the safety of the rails themselves or their compatibility with the bed and mattress. Denture cleaner tablets (bleach based) were seen on trolleys in the bathrooms. There was no risk assessment for the use of these and as residents could access these they were a potential source of harm. There was a recent accident record of a resident attempting to eat denture cleaner tablets. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 2 X 2 Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement Each resident must have a written plan as to how their needs in respect of their health and welfare so that staff know how to meet their needs. (Previous timescale of 01/06/06 not met) An appropriately sized Controlled Drug cupboard must be obtained so that CDs are stored securely. Regular audits of the Controlled Drugs must take place to ensure that the balances are correct. All the required documents must be obtained and kept on file for new employees so that it can be shown that they are suitable to be employed (Previous timescale of 01/06/06 not met) Bedside rails must not be used unless there has been a thorough risk assessment to show that they are in the best interests of the resident. Denture cleaner tablets must only be used following a risk assessment to show that the resident can use these safely. Timescale for action 31/07/07 2 OP9 13(2) 31/07/07 3 OP29 19 20/07/07 4 OP38 13(4)(c) 31/07/07 Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 25 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 OP2 Good Practice Recommendations All residents should receive a copy of their terms and conditions of residency at the time they move into the home so that there is no potential for misunderstandings to occur about what will be provided. Prospective residents should receive a letter telling them whether their needs could be met at the home so that they can be confident that they will receive the right care. The review of the residents’ care plans should state an indication of whether the care being given is effective or not. The temperature of the medication storage area should not exceed 25 degrees Celsius so that the effectiveness of the medications is not reduced. All handwritten instructions on the medicines administration records should be signed and witnessed to reduce the risk of errors occurring. Medications should be destroyed at the time they are no longer needed so that there is no risk of them being misused Oramorph bottles should be dated on opening so that it is known when they should be disposed of. Each resident should have their own toiletries. These should not be left in bathrooms to prevent them being used communally. There should be records of the activities done with each resident so that it can be shown that their social and recreational needs are being met. Each item in a pureed diet should be served separately so that the meal looks attractive and appetising. A programme of routine maintenance and redecoration should be produced. The Nurses and Midwives Council should be contacted to validate PINs of the Registered Nurses to ensure they are registered with the Council. DS0000066412.V340063.R01.S.doc Version 5.2 Page 26 2 3 4 OP3 OP7 OP9 5 6 7 8 9 OP10 OP12 OP15 OP19 OP29 Church View (Nursing Home) Limited 10 11 12 OP30 OP33 OP35 13 14 OP36 OP38 All new care staff should receive a structured induction programme to ensure that they have the skills and knowledge to do their work There should be systems to audit the quality of care provided at the home so that any deficiencies can be identified and acted upon. There should be accurate and up to date records to show transactions and what balance of money is held on behalf of residents at the home. This would ensure that any financial dealings could be properly explained. All care staff should receive supervision up to six times per year so that they receive guidance and monitoring of their daily practice. All portable appliances should be tested each year to ensure they are safe for use. Church View (Nursing Home) Limited DS0000066412.V340063.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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