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Inspection on 02/10/07 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 2nd October 2007.

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

People are cared for in a respectful manner, this ensures that their self esteem and dignity are respected and maintained.Choices of meals are offered and food is well presented. The home can cater for specialist diets and meet peoples cultural preferences. This ensures that people receive a wholesome and appropriate diet to meet their health needs and personal preferences. Aids and adaptations are provided so that independence and choices are encouraged to promote people in living their preferred lifestyle. There is a robust system in place for the safekeeping of peoples personal monies to enable them to maintain control and to access it when required. The home operates a good mechanism for medications and regular audits are carried out to ensure that a safe system is being maintained. This ensures that people receive their medications as prescribed to promote their health and well being. The standard of accommodation is good and staff ensure that people live in a clean and homely environment. There are strong health and safety arrangements in place this suggests that the protection of people living in the home is paramount. Comments received included: "Its rather a nice place" "They do the best they can" "Its quite a good home" "The girls are nice" "The activities organiser is very good" "Agency staff aren`t as good as the home staff"

What has improved since the last inspection?

The manager has introduced a new system for the pre-admission assessments of prospective residents. The recording seen of the latest admission indicated that comprehensive information is gathered to enable the home to determine if it is able to meet the persons needs before a placement is offered. The home has purchased a number of stacking chairs to ensure an adequate supply is available for people to use in their bedrooms when holding confidential discussions with their visitors. A direct delivery service was organised by the home for a person who was experiencing difficulties in obtaining adequate supplies of continence products.There was evidence that peoples personal preferences were being actioned such a one who prefers milky drinks throughout the day and another who requested a wider range of hot food at supper time. A large screen television had been ordered to improve viewing for people who have limited vision. Postural support chairs have been purchased for people who have poor ability to balance when in a seated position. Following an evaluation of the care plans a system has been introduced to improve the quality of the information provided for staff to meet peoples specific needs. This work has led to increased staff knowledge of peoples needs. Further work needs to be carried out to ensure consistency and attention to detail is applied. The home has employed an activities organiser who has received relevant training. This initiative has been well received by people living in the home as they are being provided with physical and mental stimulus to enrich their lives. There is a rolling programme of redecorating to ensure that people live in pleasing accommodation. All of the housekeeping staff have successfully completed NVQ training, this promotes their ability to carry out their roles. All catering staff have undergone training in auditing for food hygiene. This suggests that good hygiene practices are adhered to thus preventing incidences of cross infections. The manager now receives supernumery support from a senior nurse who assists with the day to day operations of the home.

What the care home could do better:

Some further works need to be carried out to care plans to ensure attention to detail and consistency of information is ensured.

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 2nd October 2007 09:10 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.V347017.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.V347017.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.V347017.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 October 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. 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.V347017.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know that the fieldwork visit would be carried out; this is to enable the inspector to obtain a true picture of the standards of the services provided. On the day of the visit, the home had 41 people living at the home. Assistance with the inspection process was provided by the manager. At the conclusion feedback was given to the manager. No Immediate Requirements were made. Information was gathered from speaking with people who reside at the home, relatives and staff. 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 carried out. Two of the four care plans reviewed were case tracked. This involves obtaining information about individuals’ experiences of living at the home. This is done by meeting with or observing people, discussing their care needs with staff, looking at care plans and focussing on outcomes. Tracking peoples care needs and how the care is delivered helps us to understand the experiences of those people. Prior to the visit the home had completed the annual quality assurance assessment and sent it to us. The information within the document advised of what the home does well, improvements made during the last 12 months and what the home would like to further improve. This provided details that contribute to the inspection process and highlights areas that may be explored during the fieldwork visit. A number of people who live at the home were requested by the inspector to complete a questionnaire. These give personal opinions about the services provided and are included in this report. The focus of inspections undertaken by us is based upon the outcomes for people who live in the home and their views about the services provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and aspects of service provision that need further development. What the service does well: People are cared for in a respectful manner, this ensures that their self esteem and dignity are respected and maintained. Cole Valley Nursing Home DS0000024835.V347017.R01.S.doc Version 5.2 Page 6 Choices of meals are offered and food is well presented. The home can cater for specialist diets and meet peoples cultural preferences. This ensures that people receive a wholesome and appropriate diet to meet their health needs and personal preferences. Aids and adaptations are provided so that independence and choices are encouraged to promote people in living their preferred lifestyle. There is a robust system in place for the safekeeping of peoples personal monies to enable them to maintain control and to access it when required. The home operates a good mechanism for medications and regular audits are carried out to ensure that a safe system is being maintained. This ensures that people receive their medications as prescribed to promote their health and well being. The standard of accommodation is good and staff ensure that people live in a clean and homely environment. There are strong health and safety arrangements in place this suggests that the protection of people living in the home is paramount. Comments received included: “Its rather a nice place” “They do the best they can” “Its quite a good home” “The girls are nice” “The activities organiser is very good” “Agency staff aren’t as good as the home staff” What has improved since the last inspection? The manager has introduced a new system for the pre-admission assessments of prospective residents. The recording seen of the latest admission indicated that comprehensive information is gathered to enable the home to determine if it is able to meet the persons needs before a placement is offered. The home has purchased a number of stacking chairs to ensure an adequate supply is available for people to use in their bedrooms when holding confidential discussions with their visitors. A direct delivery service was organised by the home for a person who was experiencing difficulties in obtaining adequate supplies of continence products. Cole Valley Nursing Home DS0000024835.V347017.R01.S.doc Version 5.2 Page 7 There was evidence that peoples personal preferences were being actioned such a one who prefers milky drinks throughout the day and another who requested a wider range of hot food at supper time. A large screen television had been ordered to improve viewing for people who have limited vision. Postural support chairs have been purchased for people who have poor ability to balance when in a seated position. Following an evaluation of the care plans a system has been introduced to improve the quality of the information provided for staff to meet peoples specific needs. This work has led to increased staff knowledge of peoples needs. Further work needs to be carried out to ensure consistency and attention to detail is applied. The home has employed an activities organiser who has received relevant training. This initiative has been well received by people living in the home as they are being provided with physical and mental stimulus to enrich their lives. There is a rolling programme of redecorating to ensure that people live in pleasing accommodation. All of the housekeeping staff have successfully completed NVQ training, this promotes their ability to carry out their roles. All catering staff have undergone training in auditing for food hygiene. This suggests that good hygiene practices are adhered to thus preventing incidences of cross infections. The manager now receives supernumery support from a senior nurse who assists with the day to day operations of the home. What they could do better: 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.V347017.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.V347017.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with adequate written details about the home for them to make an informed decision about living at the home. Senior staff gather sufficient information about a persons needs to enable the home to demonstrate that it is able to meet those needs at the time of admission. EVIDENCE: The certificate of registration was clearly on display for people to refer to. A copy of the statement of purpose and service user guide were available at the reception area for people to read at their leisure. The documents provide prospective users of the service with adequate information about the services that the home provides to assist them in decision making. They also contain advise about how the admission process is carried out. Cole Valley Nursing Home DS0000024835.V347017.R01.S.doc Version 5.2 Page 10 The pre-admission assessment information regarding the last admission was noted to be comprehensive. This will ensure that both the prospective resident and the home are able to determine that the persons needs can be met by the time they move into the home. The new procedure developed by the home assists staff in demonstrating that the aspects identifies will be used as a framework to develop the care plan. Six weeks after admission a review is conducted by both parties; if satisfactory the placement is made permanent. Cole Valley Nursing Home DS0000024835.V347017.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. Peoples healthcare and personal care needs were being well met and on the whole this was evidenced in the care planning process. The arrangements for medications are good, this ensure that people receive their prescribed drugs to promote their health and well being. EVIDENCE: Each person has a written care plan. This includes assessments and detailed information about what staff need to do to promote the persons health and well being. The files will also include various means of monitoring peoples health to assist staff in identifying if extra input is required. Care plans were found to be much improved and provided staff with good staff guidance to enable them to meet the identified needs. Some information was very detailed such as how to communicate and the home should be commended for this. There were details about peoples personal preferences such as likes horlicks and a snack prior to retiring and in another file details Cole Valley Nursing Home DS0000024835.V347017.R01.S.doc Version 5.2 Page 12 were found regarding the possible triggers of difficult to manage behaviour. Details about peoples night time preferences and trends had been recorded to assist staff in maintaining a regular sleep pattern after admission. On the whole care plans provide a global picture of peoples needs and how they should be met. Some minor shortfalls and inconsistent information were found in the four care plans that were sampled. The assessment of a person for use of a stand aid stated, ‘it is not needed because xxxxx can walk’. Staff need to explore peoples personal preferences about how often and method of bathing that individuals prefer. One file did not state when the individual wishes to retire and rise each day. A care plan about a persons mobility was not clear about how much a wheelchair was required. Some new forms introduced rely mainly on ticks being entered, these were not adequately personalised. One file was lacking a short term care plan about the chest infection and how it was being treated and monitored. Recordings about a catheter failed to state how often the catheter should be changed and that the person had had a urinary tract infection but this information had not been incorporated into the care plan. The home must ensure that the pre-typed forms in respect of difficult to manage behaviour are pertinent to the individual. Some relatives said, “There is nothing to moan about here, as a matter of fact its actually improved. Its quite a good home, xxxxx was discharged from hospital with pressure ulcers that the home has sorted out”. There was good evidence that external professionals see people who live in the home when required to ensure that they receive the specialist services to promote their health and well being. A wide range of specialists are consulted and home staff put into action any recommendations that they make. The management of medication arrangements were reviewed. Copies of prescriptions are kept so that staff can check that they have received the correct drugs into the home. Medications received in blister packs and boxes had been administered as prescribed. The process for safe storage, recordings and disposal of medications were found to be satisfactory. The arrangements for controlled drugs were found to be robust and safe. The primary care thrust carries out an audit of the systems every three months and no concerns were raised at the last one carried out. People appeared to be well kempt and dressed appropriately for the time of year; also personal preferences were reflected. Staff were observed to interact well with people and were noted talking to them about what they were doing and why to ensure that they were informed and consulted with. Cole Valley Nursing Home DS0000024835.V347017.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 meets the expectations of people; providing them with interest and pleasure. People are able to exercise choices about their daily routines and the way in which they prefer to live. A wholesome and varied diet is offered that is culturally appropriate and specialist diets are catered for. EVIDENCE: Some positive changes in the arrangements for activities were noted. The home had recruited an activities organiser who was also a carer so she had a good insight into the types of activities that people would prefer to be offered. The shifts covered by her may include weekends to ensure that the range of options are well organised and presented to people effectively. The home also has a programme of recreations on display in the reception area and relatives and friends are encouraged to participate and where possible provide assistance. The programme indicated that people are offered physically and mentally stimulating activities that caters for a range of tastes. Cole Valley Nursing Home DS0000024835.V347017.R01.S.doc Version 5.2 Page 14 The activities organiser was observed during the visit. She displayed good ability to motivate people and ensured that people of ethnic origins were included in the activity. People appeared to be enjoying either participating or watching the recreation; a positive atmosphere was noted. Also a trained nurse is able to communicate with them and acts as a translator for other staff. Their families are very supportive in that they visit daily and also act as advocates on behalf of their relative. This assists in ensuring that peoples are consulted and listened to. The activities organiser makes recordings in the care plans of who has participated with activities and weather they enjoyed the session. External entertainers are invited into the home to provide sessions such as movement to music, violinist, and pat the dog. Peoples spiritual needs are catered for with regular visits made by clerical staff of varying denominations. No external outings had been arranged. People are encouraged and supported in going out with their visitors. One person said, “My son and his wife took me to a show where they live”. Due to the mental health illness of the majority of people who live in the home regular meetings are not held. However, to compensate the manager holds a weekly evening session where visitors can hold private conversations with her to gain clarification of to express any concerns they are feeling and to act as advocates. This ensures that people are consulted about how they wish to live in the home. The homes meal menu indicated that people are offered a varied, nutritious and balanced diet. There was good evidence of choices being offered and that the kitchen staff have responded to individual requests. Breakfast is served from a hot trolley to individuals in their bedrooms. Lunch is the main meal of the day and the evening meals are both served in the main dining room. People can choose to take their meals in a lounge or their bedroom throughout the day. The dining tables were attractively presented and staff provided appropriate and discreet assistance. The lunch time meal was plated, covered and labelled by kitchen staff and carers transferred the meal to the tables. They were noted to be nicely presented. The home had some people of ethnic minorities living there. One of the kitchen assistants who is of a similar culture prepares their meals to ensure that they meet personal preferences. A comment was made about the meals: “Its alright, sometimes I have something that’s not on the menu” Cole Valley Nursing Home DS0000024835.V347017.R01.S.doc Version 5.2 Page 15 Cole Valley Nursing Home DS0000024835.V347017.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. People know that their opinions are listened to and acted on and they know how to make a complaint. The arrangements regarding adult protection are good and this protects people from risks of abuse. EVIDENCE: There is a comprehensive complaints procedure which is readily accessible to people living in the home and their representatives. The home is encouraged to produce it in large print, audiocassette and alternative languages to ensure that it is fully understood by all relevant people. The home has not received any complaints since the last inspection, however CSCI was made aware of a concern raised by a social worker during a review. The information was passed to the home to investigate and the outcome was that no Regulations had been breached. The home uses the extensive policies created by local authorities for dealing with adult protection. The home also has its own comprehensive policy. All staff have received training in this aspect of care. No concerns have been noted by the home or any agencies since the previous inspection. Cole Valley Nursing Home DS0000024835.V347017.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A homely, clean and comfortable environment is provided for people to live where they appear to feel safe and secure. 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. During warm weather people are encouraged to use the seating areas in the attractive and enclosed garden. Cole Valley Nursing Home DS0000024835.V347017.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. With the exception of one bedroom, there was no evidence of mal odour. One person who lives in the home said, “It smells lovely and fresh”. 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.V347017.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. The home maintains adequate staffing levels to meet the individual needs of the people living in the home. Staff undertake appropriate training to give them the knowledge and skills to carry out their roles effectively in delivering good standards of care. EVIDENCE: The staff rota indicated that adequate staffing levels are rostered 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 confirmed that newly appointed care staff undertake an induction programme that mirrors the contents of the Skills for Care programme that is the recognised means of providing them with the basic skills required for working within the care sector. Cole Valley Nursing Home DS0000024835.V347017.R01.S.doc Version 5.2 Page 20 Of the carers currently employed 70 have successfully completed training in NVQ level 2 and four were undertaking level 3 in care. All staff appeared to have received the relevant mandatory training in health and safety, moving and handling and fire safety. Other courses were being provided for nutrition, medications, First Aid and Infection Control. Catering staff had also received training in safe preparation of healthy meals. This ensures that staff are able to carry out their roles effectively and meet peoples specialist needs. The manager was recommended to produces a staffing matrix to assist in easily recognising when training has been provided and when refresher courses are required. This work was commenced before the inspector had left the premises. Cole Valley Nursing Home DS0000024835.V347017.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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is striving to improve the services provided for the benefit of the people who live in the home. Regular health and safety checks are carried out; this safeguards people living in the home and others from risks of injuries. 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 senior trained nurse who is at times supernumery supports the manager and the organisation of the home. Another trained nurse also works two days a month and oversees the mechanism for Cole Valley Nursing Home DS0000024835.V347017.R01.S.doc Version 5.2 Page 22 medications. This also assists the manager in the day to day running of the home. 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. Audits are carried out every three months to ensure that practices continue to be consistent and safe. 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.V347017.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 X 3 3 X 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 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 x x 3 Cole Valley Nursing Home DS0000024835.V347017.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)(2) (b) Requirement Care plans must be accurate and consistent. Short term care plans must be implemented and pre-typed generic forms must be personalised for the individual it refers to. This is needed to ensure that staff are given the necessary guidance to meet evryones needs. 2. OP33 24(1)(2) (3) The home must further develop the quality assurance system and include an annual report, which is shared with residents and staff. Timesclae of 15/01/07 has not been met, therfore this should be treated as matter of priority. 31/01/08 Timescale for action 31/12/07 Cole Valley Nursing Home DS0000024835.V347017.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. 2. Refer to Standard OP1 OP16 Good Practice Recommendations The home is advised to produce the service user guide in large print and/or audiocassette and various languages. The home is advised to produce the written complaints procedure in large print, audiocassette and otrher languages. The bedroom that has a high degree of malodur should be maintained to an accpetable level of hygiene for the occupant. 3. OP26 Cole Valley Nursing Home DS0000024835.V347017.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-56 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.V347017.R01.S.doc Version 5.2 Page 27 - 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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