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Inspection on 13/06/06 for Conifers Nursing Home

Also see our care home review for Conifers Nursing Home for more information

This inspection was carried out on 13th June 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 home carries out a pre admission assessments before a resident is admitted to the home to make sure that the home can meet the person`s needs. Following the assessment the home then confirms in writing, to the prospective resident, that the home is able/not able to meet their needs. The relationships between residents and staff appeared to be very good. Staff were seen to be sensitive to individual resident needs and were seen sat chatting to residents. One resident said, "the staff are always kind and helpful".From observations of the inspector and talking to staff and residents at the home it appeared that the privacy and dignity of residents was protected and that residents were able to have choice with regard to their every day life. To make meal times more enjoyable for residents the home sets the tables with attractive table clothes and crockery. In an attempt to ensure the privacy and dignity of residents, who perhaps require help with feeding or who experience some problems with eating, visitors to the home are requested not to sit at the dining room table while the residents eat their meal. On the day of this visit some residents were seen enjoying their lunch on the side patio area, sat under a gazebo. Following a request at the last residents meeting the lunch on the day of the visit was Irish cabbage with meat and boiled potatoes. The home offered a choice of meals at each mealtime and residents spoken to said that they were happy with the choice and quality of food. Individual resident needs and likes/dislikes were catered for by the home. Meal times were seen to be a relaxed social occasion. Food stocks were examined, which included fresh fruit and vegetables. The kitchen was clean, well organised and food was seen to be appropriately stored. The home had an open visiting policy, staff, residents and a visitor to the home confirmed that visitors could be seen in any of the communal areas of the home or in the privacy of residents` own rooms. The staff flies inspected contained all the necessary recruitment checks to make sure that staff are able to work safely with the residents. Staff were appropriately trained within the home and all new members of staff have a 6week induction training. The home looked after residents` monies safely.

What has improved since the last inspection?

The previous inspection report identified some areas of work within the home that needed improving. The home has taken the steps to look at all these areas and have undertaken the work needed to make the improvements necessary. These included improving the residents care plans, being more accurate with recording of medication, recording that activities are discussed with residents to make sure that the activities provided are what the residents want to do. At the last inspection the home had put a bid to Age Concern for funding for a part time activity co-ordinator. Unfortunately the bid was not accepted. However, a member of care staff, who had already shown an interest in taking on the role of the activity co-ordinator has been given extra hours to take on the role and this appears to have been very successful. Since the last inspection the lounge and lounge/dining has been re-decorated and had new carpets and curtains fitted. This area looks now more attractive, brighter and airier. The home has bought 2 new televisions, a DVD, a new stereo and some new lamps and table clothes. Also some new patio furniture has been bought. Several bedrooms have been re-decorated and have had new carpets fitted. Also the home has bought some new hospital type beds and new bed rails and safety bumpers.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Conifers Nursing Home 158 Manchester Road Chorlton Manchester M16 0DS Lead Inspector Geraldine Blow Key Unannounced Inspection 13th June 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Conifers Nursing Home DS0000021639.V299590.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. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Conifers Nursing Home Address 158 Manchester Road Chorlton Manchester M16 0DS Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 881 2514 0161 862 9635 Dr VK Trehan Mrs S Trehan Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The numbers of those requiring nursing care at any one time shall not exceed 23 patients of either sex aged 60 years or over A maximum of 2 persons per day are provided with nursing day care in the home. Registration is subject to compliance with the minimum nursing staffing levels indicated in the Notice which was previously served in accordance with Section 25 (3) of the Registered Homes Act 1984 dated 4 April 2001. 14th March 2006 Date of last inspection Brief Description of the Service: Conifers Nursing Home is registered to provide accommodation and nursing care for up to 23 older persons. It is part of a family run business, which includes one other nursing home and a residential home. The registered provider is Dr. V Trehan. The home is situated on a busy main road in the Chorlton area of Manchester. It is close to local facilities, bus routes and the city centre. Accommodation is provided on two floors, served by a passenger lift and the home is accessible to residents who use a wheelchair. Bedroom accommodation is on the ground and first floor. There were 7 single bedrooms, 2 of which offer en-suite facilities and 8 double bedrooms. All rooms offer the facility of a wash hand basin. There are 2 lounges and one lounge/ dining area. There is a paved patio to the side and the rear of the home, which are accessible to residents via patio doors and a ramp. The proprietor has purchased further land to the rear of the property and has plans to landscape the area. Until the area has been landscaped residents are not using the rear patio. There is a small designated smoking area on the ground floor. The charges for fees range from £350.51 to £399.10 per week. Information about the home can be gained through contacting the registered provider, Dr V Trehan. The CSCI inspection report is available at the home and through the CSCI Internet site. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by CSCI since the last inspection on 14 March 2006 and some supporting information received in the preinspection questionnaire that was submitted to CSCI by the home and the requirements made at the last inspection. This visit was Unannounced and forms part of the overall inspection process and it took place on Tuesday 13 June 2006. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS) and the requirements made at the inspection on 14 March 2006. This inspection was also used to decide how often the home is to be visited to make sure that it meets the required standards. This inspection was an Unannounced visit because the Commission for Social Care Inspection (CSCI) has some concerns that the home has been unable to appoint a manager for some time. For this reason the owner of the home was invited to meet with the inspector during the visit to discuss the situation. The owner of the home was able to give the inspector details of the efforts he has made to appoint a manager and details of his plans future plans to address the situation. As part of the visit time was spent with the residents who live at the home, a visitor to the home, observing how staff work with residents, discussions with the care management consultant, the senior nurse and the senior nurse for administration, assessing relevant documents and files and a tour of the premises was undertaken. The CSCI had not received any complaints or concerns about the home since the last visit. What the service does well: The home carries out a pre admission assessments before a resident is admitted to the home to make sure that the home can meet the person’s needs. Following the assessment the home then confirms in writing, to the prospective resident, that the home is able/not able to meet their needs. The relationships between residents and staff appeared to be very good. Staff were seen to be sensitive to individual resident needs and were seen sat chatting to residents. One resident said, “the staff are always kind and helpful”. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 6 From observations of the inspector and talking to staff and residents at the home it appeared that the privacy and dignity of residents was protected and that residents were able to have choice with regard to their every day life. To make meal times more enjoyable for residents the home sets the tables with attractive table clothes and crockery. In an attempt to ensure the privacy and dignity of residents, who perhaps require help with feeding or who experience some problems with eating, visitors to the home are requested not to sit at the dining room table while the residents eat their meal. On the day of this visit some residents were seen enjoying their lunch on the side patio area, sat under a gazebo. Following a request at the last residents meeting the lunch on the day of the visit was Irish cabbage with meat and boiled potatoes. The home offered a choice of meals at each mealtime and residents spoken to said that they were happy with the choice and quality of food. Individual resident needs and likes/dislikes were catered for by the home. Meal times were seen to be a relaxed social occasion. Food stocks were examined, which included fresh fruit and vegetables. The kitchen was clean, well organised and food was seen to be appropriately stored. The home had an open visiting policy, staff, residents and a visitor to the home confirmed that visitors could be seen in any of the communal areas of the home or in the privacy of residents’ own rooms. The staff flies inspected contained all the necessary recruitment checks to make sure that staff are able to work safely with the residents. Staff were appropriately trained within the home and all new members of staff have a 6week induction training. The home looked after residents’ monies safely. What has improved since the last inspection? The previous inspection report identified some areas of work within the home that needed improving. The home has taken the steps to look at all these areas and have undertaken the work needed to make the improvements necessary. These included improving the residents care plans, being more accurate with recording of medication, recording that activities are discussed with residents to make sure that the activities provided are what the residents want to do. At the last inspection the home had put a bid to Age Concern for funding for a part time activity co-ordinator. Unfortunately the bid was not accepted. However, a member of care staff, who had already shown an interest in taking on the role of the activity co-ordinator has been given extra hours to take on the role and this appears to have been very successful. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 7 Since the last inspection the lounge and lounge/dining has been re-decorated and had new carpets and curtains fitted. This area looks now more attractive, brighter and airier. The home has bought 2 new televisions, a DVD, a new stereo and some new lamps and table clothes. Also some new patio furniture has been bought. Several bedrooms have been re-decorated and have had new carpets fitted. Also the home has bought some new hospital type beds and new bed rails and safety bumpers. 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. Conifers Nursing Home DS0000021639.V299590.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 Conifers Nursing Home DS0000021639.V299590.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home undertakes an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: The home conducts a pre-admission assessment of prospective residents prior to admission to ensure that the home can meet all their assessed needs. Following this assessment the home confirms in writing to the prospective resident that they are able/not able to meet their assessed needs. For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. The home does not provide an intermediate care service Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Each resident had an individual plan of care, which promoted privacy and dignity. The systems and procedures for dealing with medicines protected residents. EVIDENCE: A random sample of care plans were examined. Evidence was seen of ongoing work to improve the documentation of the care planning system since the last inspection. In addition care planning training is included in the induction process. The care files had been indexed and were in an easy format for all staff to use. Each individual file was found to contain an up to date photograph of the residents for easy identification. The plans of care were found to be detailed, informative and clearly set out the action that needed to be taken by care staff to ensure that all aspects of health, personal and social care needs of the residents were met. It was encouraging to note that privacy and dignity was Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 11 promoted within the care plans. The plans of care had been reviewed on a monthly bases and updated accordingly. All sections of the care plans had been appropriately signed and dated. Good practise could be evidenced where a summary of the risk assessments had been included in the front of the file so that all risks are easily identified. This is considered a piece of good practise. Although as identified at the last inspection the actual risk assessment was vague and lacked detail. They did not appropriately identify any potential risks or the action to be taken to minimise the risk. The requirement has been reiterated in this report. Evidence was seen of peoples’ Care Management reviews that were undertaken to ensure that the overall care and support of the resident was continued to be met at the home. As required at the last inspection the daily log sheets were seen to contain more detail to reflect the nursing care provided to residents. All residents were registered with local General Practitioners and had access to visiting healthcare professionals e.g., Dietician, Chiropody, Dentistry and Ophthalmology. This ensured residents were in receipt of appropriate health services necessary to support their health care needs. Evidence was seen that the Medication Administration Recording (MAR) sheets were recorded accurately and all deliveries and disposal of waste medication had been signed so providing a full audit trial. However it is recommended that 2 staff witness and sign for the disposal of waste medication. In line with the Royal Pharmaceutical Guidelines the home did receive and sign the exemption declaration on the back of the prescription prior to them being submitted to the pharmacy for dispensing. Practice at the home could be improved if the home kept a copy of the GP’s original prescription for reference if there was any query regarding residents medication. It was encouraging to note that medication with a limited life had the date of opening clearly marked to ensure out of date medications are not given to residents and therefore protecting and safeguarding their health. From observations made during the inspection and discussions with members of staff, residents and a visitor to the home it appeared that the nurses and care staff treated the residents with respect and dignity. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Activities were provided and residents were able to maintain contact with family and friends. Residents were able to exercise choice and control over their lives and the residents enjoyed the meals that they choose. EVIDENCE: At the last inspection the home had made a bint to obtain funding from Age Concern. This bid was not successful and as stated earlier in this report the home has allocated a member of care staff extra hours that are dedicated to activities. There was evidence that activities are discussed at the residents/relative’s meetings and those suggestions are then actioned. For example the home held a buffet to celebrate the Queens Birthday in April 2006. The residents really enjoyed the buffet and a suggestion was made that the home hold regular buffets. Other activities include various board games as suggested by residents. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 13 Care plans include an activity assessment that is completed on admission and records the preferred interests of residents. Each resident has a record of activities undertaken. The home had a visiting policy and visitors could be received in the residents’ own room or any of the communal areas of the home. Residents, staff and a visitor to the home confirmed this. From speaking to residents and staff it appeared that residents are able to exercise choice and control over their lives and that residents are able to bring personal possessions into the home. The menu examined demonstrated that the home provided a varied diet, which was nutritionally balanced. An alternative to the main meal was available and residents and staff confirmed this. At the time of this visit the home were not providing any specific cultural diets. The care management consultant said that these needs are assessed during the pre admission assessment and the home has in the past catered for specific cultural needs and individual preferences. One former resident liked cornmeal porridge so this was made on a daily basis for her. The finding room had a daily menu on display. Residents spoken to said that they were satisfied with the meals served in the home. It was encouraging to note that the minutes of the last residents meeting demonstrated that residents would like to have “proper Irish cabbage”. This was being served on the day of this visit. Also the residents had requested to have black pudding and Eccles cake. Both of these requests had been honoured. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home encourages and supports people to raise their concerns and complaints and had the policies, procedures and systems in place to protect residents from abuse. EVIDENCE: The home had a complaint procedure, which was on on display, and a copy was included in the Service User Guide, which every resident had been given. One resident said that she had never wanted to make a complaint but if she did she would just talk to one of the nurses. The visitor to the home said that she had never made a complaint but if she had any concerns she would go to either a nurse or Joe (the care management consultant) and she felt they would take her concerns seriously. The care management consultants said that the home operated an open door policy where residents and visitors were encouraged to discuss any worries or concerns with the home staff. The home maintained a complaint file, which contained details of the complaint, staff statements, the actions taken and the outcomes. Since the last inspection the home had not received any complaints. The home had policies and procedures in relation to protection of adults from abuse and Whistle Blowing. The wording of the Protection of Vulnerable Adults policy needed amending as it suggested that the home would investigate an Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 15 allegation of abuse. The inspector was assured that this would be done immediately. The home had a copy of the Manchester and Multi-Agency Policy on the Protection of Vulnerable Adults from Abuse. During discussions with staff and the care management consultant it was evident that they were aware of the correct procedure to take in the event of an allegation of abuse. It was reported that staff had received training on the action to be taken in the event of an allegation of abuse and this was also included in the induction process. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service All areas of the home were generally clean however some furnishings were not well maintained. EVIDENCE: The location and layout of the home was suitable for its stated purpose. Although some areas of the home had been re-decorated and re-carpeted since the last inspection, some areas of the home were showing signs of general “wear and tear”. For example, the bedroom furniture in room 2 looked old and worn, in several bedrooms drawers had handles missing and drawers were ill fitting. Generally the home was clean and there were no offensive smells. However, the arms of an easy chair in room 1 appeared dirty and stained and the Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 17 wheelchair in the same room was poorly maintained. It is recommended that the registered provider produce a programme of maintenance and renewal of fabric and decoration of the premise based on his own audits and the comments contained within this report. As already referenced in this report the rear patio area was not currently being used for residents, as the contractors were due in to level off and landscape the area that the proprietor had recently purchased. However it was encouraging that the side patio area was being utilised for resident’s use. A gazebo had been erected and new patio furniture and pot plants had been purchased to make the area attractive for residents to enjoy. Laundry facilities are sited away from the food preparation area. The home had policies relating to infection control and it was noted that protective personal equipment (PPE) was stored in all toilets, bathrooms and residents bedrooms where personal care was being delivered, in line with the latest Infection Control Guidelines. This is seen as good practise. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The number and deployment of staff appeared sufficient to meet the residents’ assessed needs and the home was unable to demonstrate that its staff had completed the required training to meet residents’ needs. The procedures for recruiting staff were robust and provided adequate safeguards to protect residents. EVIDENCE: On the day of the inspection site visit the staffing numbers and skill mix appeared appropriate to meet the needs of the residents accommodated. The home had recently appointed a senior nurse who was responsible for administration and at the time of this visit she was working supernumery as part of her induction process. The home employed 9 care staff. Of these 9 members of care staff 3 had successfully achieved the NVQ Level 2 Award. Three members of care staff were adaptation nurses who were currently undertaking their adaptation training. The care management consultants said that the home was fully staffed at the moment. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 19 The staff files examined all contained the appropriate documentation as required by Schedule 2 of The Care Homes Regulations 2001. New files contained POVA 1st checks and all files contained two written references. The staff files contained an individual training and development plan. Evidence was seen of regular staff training and mandatory updates, however it is recommended that the individual programmes be updated to include the dates the training was attended in order for the home to easily evidence that all staff are appropriately trained. The home had a structured Induction Process, which had been reviewed, and included the new Skills for Care Induction Modules, which will be introduced in September 2006. All new starters must complete the induction process which takes 6 weeks to complete. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 28 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home did not have a registered manager the homewas being effectively managed by the management consultant and the senior nurse. Systems were in place to monitor the service based on peoples’ views and appropriate procedures were in place to protect the health and safety of people living at the home. EVIDENCE: The home has been without a manager for some time although the provider has made attempts to recruit to this position. During this visit the provider gave documented details to the inspector of the action he has already taken to address the situation and details of his proposed course of action. The matter Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 21 will be addressed directly with the homes provider. However a requirement has been made with timescales for the provider to address the matter. Evidence was seen that a quality audit system was in place. Quality audit questionnaires have been developed and are due to be given to residents, relatives and visiting professionals. A quality meeting has been arranged for 20 June 2006 to discuss the quality questionnaire and the purpose of the questionnaires being distributed. Once the results of the questionnaires have been reviewed an action plan is will developed and published based on the results. The published document is made available for public viewing. Evidence was seen of regular staff and residents/relatives meetings. The home has a policy and procedures file that is available to all staff. The file is reviewed on an annual basis or more frequent if needed. Evidence was seen that staff were receiving formal supervision 6 times a year. The dates for supervision for the whole year is booked in advance and given to the staff. The home is only responsible for the personal allowance of 1 resident. However, there is evidence that the home keeps ‘pocket money’ for residents that is given to them by the resident’s representatives. The home maintains a running balance, written transactions are maintained and receipts are kept for all purchases to ensure that monies are effectively managed. Evidence was provided that the home’s maintenance certificates and records were up to date in order to protect the residents and staff employed. Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 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 3 3 x x x x x 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 2 x 3 x 3 3 x 3 Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes NO 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 Requirement The plan of care must include detailed risk assessments. (Previous timescale of 30/4/06 had not been met.) The registered provider must forward a registration application for a manager to be registered with the CSCI. (The previous timescales of 7/12/05 and 23/3/06 had not been met) Timescale for action 30/06/06 2. OP31 8&9 30/08/06 Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 24 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 OP9 Good Practice Recommendations 1. It is recommended that 2 staff witness and sign for the disposal of waste medication. 2. It is recommended that a copy should be kept of all GP prescriptions. It is recommended that the registered provider produce a programme of maintenance and renewal of fabric and decoration of the premise based on his own audits and the comments contained within this report. It is recommended that the individual training and development programmes are updated to include the dates the training was attended in order for the home to easily evidence that all staff are appropriately trained. 2. OP19 3. OP30 Conifers Nursing Home DS0000021639.V299590.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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