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Inspection on 16/10/06 for Cole Valley Nursing Home

Also see our care home review for Cole Valley Nursing Home for more information

This inspection was carried out on 16th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The standard of the accommodation is good and provides a clean and homely atmosphere for the persons living at the home. The home operates a robust mechanism for the administration of medications and the deputy manager regularly carries out audits. This ensures that residents receive their prescribed medications to maintain their health. As well as the positive comments made in the three comment cards received; all residents spoken to during the visit were complimentary about the services they receive. Some of the comments included, "I`m happy, I like living here they look after me". Visitors are encouraged to make hot or cold drinks for themselves as well as the resident they are visiting. This practice was observed during the visit, which contributes to the relaxed and friendly atmosphere of the home. Bedrooms are decorated when they become vacant or sooner if required to ensure pleasant and fresh personal space for residents. The home invites relatives to share a meal with their respective resident. The relative advised that the standard of meals are good. This is an independentmeans of assessing the standard of the meals provided and is also additional social event for residents. The health and safety arrangements are comprehensive; this indicates that the protection of residents is paramount.

What has improved since the last inspection?

The home has addressed 50% of the requirements made at the last inspection. Several bedrooms have been redecorated. Work has been carried out in the kitchen to improve the working conditions and safety for kitchen staff. Improvements have been made to wound ulcer documentation to facilitate staff in monitoring and provision of appropriate treatment of them. The home reported difficulties in locating a dentist during the previous inspection. The manager reported that this has now been resolved and all residents have been assessed to ensure their oral health is maintained. Some staff have arranged to commence training in NVQ level 3 to enhance their skills in caring for the people living at the home. All trained staff and one carer have completed training in dementia care to promote their abilities in providing appropriate care. Two specialist beds have been purchased to improve the facilities for residents and staff. To ensure that moving and handling aids are adequate in supply and fit for purpose three handling belts have been purchased to complement those already in the home.

What the care home could do better:

The manager needs to ensure that the induction programme for care staff reflects the recently introduced Skills for Care syllabus. The carpet of the first floor corridor is badly stained giving a shoddy appearance for residents and visitors. This needs deep cleaning or replacement. The home must evidence the formal reviews that are being carried out by developing a tool to record the outcomes and if changes are required to care plans.

CARE HOMES FOR OLDER PEOPLE Cole Valley Nursing Home 326 Haunch Lane Kings Heath Birmingham West Midlands B13 0PN Lead Inspector Kath Strong Key Unannounced Inspection 16th October 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 Cole Valley Nursing Home DS0000024835.V317753.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. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cole Valley Nursing Home Address 326 Haunch Lane Kings Heath Birmingham West Midlands B13 0PN 0121 444 8887 0121 441 1959 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) Cole Valley Care Limited Michele Laraine Clarkson Care Home 45 Category(ies) of Dementia - over 65 years of age (45), Old age, registration, with number not falling within any other category (45) of places Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 45 males and females over the age of 50 years for general nursing care That the registered manager completes the Registered Managers Award by August 2006. 16th May 2006 Date of last inspection Brief Description of the Service: Cole Valley Nursing Home is purpose built on two levels, with a passenger lift for access to the first-floor. Occupancy is for up to 45 residents of 65 years or above who may be suffering from dementia, a variation of registration permits the home to accept persons who are aged 50 years or above. The premises are located within the Kings Heath district of Birmingham, and situated in a residential neighbourhood close to local amenities including shops and public transport. The Home is pleasantly furnished and decorated and aims to offer a warm, homely environment for elderly people requiring nursing care. There is a small car park adjacent to the Home and sheltered, private gardens for service users and their visitors to frequent. There is a range of communal rooms to give residents choices about where they wish to sit. Bedrooms are located on both floors, are of single occupancy and include en-suite facilities consisting of toilet and wash hand basin. Communal assisted bathing facilities are strategically located on both floors for ease of access. There is a range of lifting aids to assist those residents who have restricted mobility. The specialist equipment includes many pressure relieving devices and other specialist items to meet the needs of residents. The accommodation charges are £545.00 per week for those who are self funding. The fee rate paid by Adults and Communities Directorate is £472.00 with residents paying a top up fee of £30.00 per week. Services not included in the fee rate are hairdressing, newspapers and magazines, chiropody and toiletries, the costs for these vary. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork was carried out over a period of seven hours; assistance was given by the manager throughout. There were 41 people living at the home on the day of the visit. Information was gathered from speaking with residents, relatives and staff including two staff interviews. Care, health and safety and the arrangements for medications were inspected. Staff personnel files were checked and staff were observed whilst performing their duties. A partial tour of the premises was undertaken including the bedrooms of the care plans that were seen. Due to dementia it was not possible to hold meaningful discussions with some residents. At the conclusion verbal feedback was given to the manager. No immediate requirements were made. Prior to the fieldwork visit the home completed and supplied CSCI with a preinspection questionnaire. Three residents also sent comment cards; all provided positive information about the home. What the service does well: The standard of the accommodation is good and provides a clean and homely atmosphere for the persons living at the home. The home operates a robust mechanism for the administration of medications and the deputy manager regularly carries out audits. This ensures that residents receive their prescribed medications to maintain their health. As well as the positive comments made in the three comment cards received; all residents spoken to during the visit were complimentary about the services they receive. Some of the comments included, “I’m happy, I like living here they look after me”. Visitors are encouraged to make hot or cold drinks for themselves as well as the resident they are visiting. This practice was observed during the visit, which contributes to the relaxed and friendly atmosphere of the home. Bedrooms are decorated when they become vacant or sooner if required to ensure pleasant and fresh personal space for residents. The home invites relatives to share a meal with their respective resident. The relative advised that the standard of meals are good. This is an independent Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 6 means of assessing the standard of the meals provided and is also additional social event for residents. The health and safety arrangements are comprehensive; this indicates that the protection of residents is paramount. What has improved since the last inspection? What they could do better: The manager needs to ensure that the induction programme for care staff reflects the recently introduced Skills for Care syllabus. The carpet of the first floor corridor is badly stained giving a shoddy appearance for residents and visitors. This needs deep cleaning or replacement. The home must evidence the formal reviews that are being carried out by developing a tool to record the outcomes and if changes are required to care plans. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive written documents are available to enable prospective residents to make an informed decision about living at the home. Preadmission assessments are carried out to ensure that the home is able to meet individual’s needs. EVIDENCE: The contents of the statement of purpose and service user guide provide sufficient information about the services of the home. Both documents are readily available and a copy of the last inspection report can be requested from the manager. The home is advised to produce the service user guide in large print and/or audiocassette for the assistance of those persons who are visually impaired. The contents of the contract of terms and conditions of residency contains all relevant information and is supplied to privately paying residents. The Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 10 manager was requested to issue a contract to all residents irrespective of the funding arrangements to ensure that residents have equal rights within the home. The contract supplied by Adults and Communities Directorate is an agreement with the home rather than the resident. Pre-admission assessments are carried out to give the home the opportunity to consider if the identified needs can be met and to ensure that any specialist equipment is acquired in readiness for the admission. The manager was observed offering a prospective resident an opportunity to visit the home at a day and time that was convenient to them. Prospective residents and their family are encouraged to stay in the home for a protracted period to give them opportunity to have a meal and to talk with residents and staff to assist them in forming an opinion. The manager advised that they may wish to make a number of visits before they have a complete picture of the services offered. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good improvements have been achieved in respect of care planning; some further work is needed to ensure that all care needs are being met. The arrangements for the administration of medications are robust and protect residents from the risk of harm. EVIDENCE: Care plans include some good instruction for staff to follow such as guidance for pressure ulcers and short term care plans for conditions such as urinary and chest infections. The life history, background information and likes and dislikes are well recorded to assist staff in how they approach and converse with residents. Monthly assessments are carried out to ensure the home has up to date information about an individuals health needs and how they should be met. Some further developments are needed for staff to be supplied with a global picture: • A care plan for the resident who suffers with back pain and has epidurals need to be developed Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 12 • • • • Care plans in respect of difficult to manager behaviour need to include possible triggers and a description of the type of behaviour displayed Completion of the already commenced work in advising staff of the sling size to be used with hoists Regular formal reviews need to include appropriate documentation and evidence that the resident and/or relevant others are involved Personal preferences need to be more specific such as bath or shower, how often and which time of the day. The home would benefit from development of a tool for this purpose. There was evidence that the home adopts a proactive approach to requesting the services of external healthcare professionals to assist staff in providing appropriate and specific care. The home has strong links with a hospice. The relationship is such that staff learn from the professionals in respect of providing comprehensive care that is tailored to the persons needs. Some comments were received from residents, “I’m happy, no complaints about the home, I like living here they look after me”. Further information provided by relatives was, “Staff give me confidence to do the things I need to get sorted, staff are always helpful and keep me informed and will telephone if necessary”. The arrangements for receiving, storage, administration and disposal of medications were found to be good. The recordings on MAR (medication administration records) included auditing of medications received from the pharmacist. The deputy manager carries out regular audits and the pharmacist checks the system every three months. The good management of medications safeguards residents from potential harm. Staff were observed using the preferred term of address towards residents. Personal care was provided discretely and in the privacy of a bathroom or the resident’s own bedroom to maintain their dignity. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 13 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 home provides varied social activities that meet the expectations of residents providing them with interest and pleasure. Residents are able to exercise choices over their daily routines and staff promote their individuality and independence. A wholesome and varied diet is offered, which meets specialist dietary needs. EVIDENCE: Due to the high number of residents with dementia pre-planning of activities is impractical. Recreations are provided late morning and/or early afternoons to accommodate those residents who tire easily. Extra care staff are rostered to provide activities and relatives are actively involved and provide further assistance. Bingo is a weekly event to encourage and facilitate family and friends who wish to join in to increase the enjoyment for residents. Care plans include a section to record if an individual has participated, this is used to monitor trends and the level of motivation. Review of the care plans indicated that a range of activities are offered that are varied and age appropriate. Board games and music to movement are regular events. External personnel visit the home to provide entertainment. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 14 The home was planning a 100th birthday party and the family were assisting with the preparations. Clerical officials visit the home and one resident receives a weekly visit. The home has a visiting library for those residents who enjoy reading. A resident goes out independently each week to a luncheon club, which is accessed by the ring and ride bus service. Another goes to church every Sunday accompanied by a relative or a carer. The manager advised that due to their mental illness residents do not choose to attend residents meetings, therefore they are not held. To compensate the manager speaks with each resident on a regular basis. She appeared to have a good relationship with relatives and other visitors. A relative entered the manager’s office and requested a different armchair for her mother, the manager promptly responded. One resident is unable to speak English; a family member visits daily and acts as an interpreter. Another person wanders around the ground floor of the home for most of the day with staff maintaining discreet observations to ensure her safety. A resident was observed entering the manager’s office; the resident, the manager and the inspector had a lengthy conversation. The manager has recently introduced a weekly evening ‘surgery’ for residents and their representatives to discuss any issues or concerns. The homes menu indicates that residents are offered a varied, nutritious and balanced diet. A local butcher supplies fresh meat. There was good evidence of choices being offered and residents confirmed this during discussions. The family report to the manager that the residents is happy with the standard of the meals for the resident who has a vegetarian diet. Breakfast is served from a hot trolley to residents in their bedrooms. Lunch was observed being served. The main courses were attractively served; soft diets and pureed foods were served appropriately. Staff were observed providing discreet assistance to ensure that residents enjoyed the experience whilst ensuring that their dignity was being maintained. One resident requested chips; these were cooked and served as soon as practically possible. A resident reported, “Lunch today was good”. A relative said, “I come in and have lunch every Sunday, the meat is really lovely, the puddings are nice and my husband often tells me how much he enjoys his meals”. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives know how to make a complaint and their opinions are listened to and handled objectively. Although the written policy regarding adult abuse is satisfactory staff have not received training to ensure that they act appropriately in the event of an allegation of abuse. EVIDENCE: There is a comprehensive complaints procedure, which is accessible to residents and their representatives, should they wish to make a complaint. The home is encouraged to produce the procedure in large print format and/or audiocassette for the benefit of those persons who have sight impairment. CSCI have received one complaint since the previous inspection concerning care practices and staff availability. Both elements of the complaint were not upheld, however the manager reported that as a result communications and relationships with the family had much improved. No other complaints have been received by the home. The Birmingham multi-agency guidelines are used in respect of adult abuse. There have been no allegations since the last inspection. Although during interview staff provided good responses to questions about abuse; they have not received training. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 16 In house training has been planned to provide them with the knowledge and skills to respond appropriately if abuse occurs or is suspected. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a warm, comfortable, hygienic and wellmaintained home to enable their needs to be met in a safe and pleasing environment. EVIDENCE: The interior of the home is well laid out in an attractive style. There is a choice of spacious communal and a secluded garden for residents and visitors to frequent. There are three well appointed lounges and a large separate dining room. All rooms are tastefully decorated and furnished and offer plenty of scope for social events. The first floor corridor carpet is badly stained and requires deep cleaning or replacement to maintain a pleasing environment for residents and their families. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 18 There is assisted bathing in the form of baths or showers for residents to choose the type of bathing they prefer. Communal toilets are strategically located throughout the home for ease of access. All bedrooms have en-suite facilities consisting of toilet and wash hand basin. The rooms visited were noted to be comfortable, contained sufficient furniture and were very personalised. Residents are encouraged to furnish the room to suit their own preferences and may take items of furniture and personal possessions into them. All bedroom doors have suited locks and some residents hold their own key to maintain their privacy and dignity. The home was clean and tidy throughout including the kitchen and laundry rooms. There was no evidence of mal odour. A relative said, “It’s always spotlessly clean and smells clean”. Random hot water temperature checks were being regularly carried out and recorded on all outlets that residents have access to prevent the risk of scalds. Cole Valley Nursing Home DS0000024835.V317753.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 adequate. This judgement has been made using available evidence including a visit to this service. Acceptable staffing levels are maintained to meet the needs of residents. The home operates a robust system for the recruitment of staff to protect residents from the risk of harm. Some staff training is needed to supply them with the knowledge and skills to carry out their role effectively. EVIDENCE: Four recent weeks of the staff rota were checked; these appear to provide adequate staffing levels for each shift. They are complemented by ancillary staff who are employed to work seven days a week. These arrangements ensure that staff are able to carry out their designated roles. The home has bank staff to cover vacant shifts for trained staff and carers. Agency staff are used as a last resort to promote continuity of care for residents. Checking of personnel files indicated that all the necessary checks are carried out and references obtained before an applicant is offered a position. This indicates that resident’s safety is paramount. The manager was requested to check that the recently introduced Skills for Care programme is being used for the inductions of care staff. Of the carers currently employed 65 have successfully completed training in NVQ level 2 and some have enrolled to undertake level 3 in care. A few staff Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 20 were noted to require training in Health and Safety, Food Hygiene and Moving and Handling. As discussed previously staff also need to complete training in adult protection. The trained staff and one carer have undertaken training in dementia care and an adapted course will be supplied to all other carers. Some staff have had training in other subjects that are relevant to residents needs. Cole Valley Nursing Home DS0000024835.V317753.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, 32, 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 manager is experienced and has the skills to oversee the day to day operations of the home. Regular audits are carried out to monitor the standards of the services provided but these need to be further developed. The health and safety arrangements are good and protect residents from the risk of injury. EVIDENCE: The manager is experienced and demonstrated motivation in making continual changes for the benefits of residents. She displayed a transparent approach to residents, visitors and delegated tasks to staff in a constructive manner. Discussions held with staff indicated that they feel well supported by the management structure. A deputy manager who is not supernumery supports the manager and the organisation of the home. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 22 A senior member of the organisation carries out unannounced visits and checks the standard of the service; this is evidenced by the regular reports maintained within the home. Satisfaction surveys are distributed to residents and relatives to complete. The maintenance operative carries out regular checks on the premises and the deputy manager audits the medications. The manager was requested to carry out further audits of such area as infection control, the kitchen and care plans and to develop a report, which includes shortfalls and how and when they will be addressed. This demonstrates the homes commitment to continually improve the services for residents. The mechanism for the safekeeping and financial transactions of resident’s personal monies was found to be good, this prevents residents from experiencing financial abuse. Staff receive regular formal supervision meetings to enable them to demonstrate to senior staff that they possess the knowledge and skills to perform their duties efficiently. The accident records were satisfactory and there is evidence of action taken to reduce risks where a trend has been identified. The home carries out the relevant checks and servicing of equipment to ensure that it is fit for purpose. The maintenance operative carries out regular checks on the integrity of the premises. The fire alarms and emergency lighting are tested and fire drills carried out with the names staff who have participated recorded to capture all of them. The arrangements appear to protect residents and others from the risk of injury. Cole Valley Nursing Home DS0000024835.V317753.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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 3 Cole Valley Nursing Home DS0000024835.V317753.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 OP2 Regulation 5(1)c Requirement Timescale for action 31/12/06 2. OP7 15(1)(2) (b) 3. OP12 16(2)(n) The registered person must supply all residents with a contract of terms and conditions of residency. The registered person must 31/12/06 ensure care plans include the following: • A description of the trigger and type of behaviour displayed in difficult to manage behaviour • Complete the commenced work of including sling sizes to be used with hoists • A care plan for the resident who experiences back pain and has epidurals • Develop a tool for conducting formal reviews and evidence of the resident and/or their representative be involved. The registered person shall 30/11/06 actively recruit an activities organiser. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 25 4. OP18 13(6) 5. OP30 18(1)(c) (i) 6. OP31 9(2)(i) 7. OP33 24(1)(2) (3) 8. OP36 17(2) Sch4 The registered person must provide training for all care staff in adult protection and how to deal with challenging behaviour. Timescale of 30/09/06 has not been met. The registered person must ensure that all staff receive training and relevant refresher courses in Moving and Handling, Food Hygiene, Health and safety and Dementia Care. This requirement has been partially met. The registered manager must achieve a recognised management qualification. Not assessed on this occasion therefore carried forward. The registered person must further develop the quality assurance system and include an annual report, which is shared with residents and staff. All written policies and procedures must be regularly reviewed and amended as appropriate. Not assessed on this occasion therefore carried forward. 31/01/07 31/12/06 31/01/07 15/01/07 30/11/06 Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP1 OP16 OP31 Good Practice Recommendations The home is advised to produce the service user guide in large print and/or audiocassette for the benefit of those persons who are visually impaired. The home is advised to produce the written complaints procedure in large print and/or audiocassette for the benefit of those persons who are visually impaired. A regular supernumery period should be allocated to the senior nurse who supports the registered manager. Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Cole Valley Nursing Home DS0000024835.V317753.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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