Inspection on 01/07/05 for Cow Lees Nursing Home

This inspection was carried out on 1st July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Cow Lees Nursing Home 24/09/08

Cow Lees Nursing Home 14/05/07

Cow Lees Nursing Home 15/05/06

Cow Lees Nursing Home 22/11/05

Cow Lees Nursing Home 29/09/04

Cow Lees Nursing Home 20/04/04

Similar services:

Coton Hill House

Doddington Lodge

Far Croft

Churchill House Nursing and Residential Home

Field Farm House

Church Terrace Nursing & Residential Home

Fountain Court

The Forbury

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

CARE HOMES FOR OLDER PEOPLE COW LEES NURSING HOME Astley Lane Bedworth Warwickshire CV12 0NF Lead Inspector Suzette Farrelly Unannounced 01 July 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 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. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Cow Lees Nursing Home Address Astley Lane Bedworth Warwickshire CV12 0NF 02476 313794 02476 316750 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr John OSullivan Ms Margaret Bailey Care Home with nursing 52 Category(ies) of Dementia - Over 65 registration, with number of places COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29 September 2004 Brief Description of the Service: Cow Lees nursing home is approximately 2 miles from Bedworth town centre in a rural setting. The Home is registered to provide accommodation to 49 elderly residents with dementia who may require nursing care. The accommodation is provided in two main care areas, those being Cow Lees House (existing building) and Astley House (new building). Accommodation in Cow Lees House is provided in mainly shared rooms. Astley House is a purpose built facility with single en - suite accommodation. Access to all care areas is via passenger lift/stairs. A number of rooms in Cow Lees have limited access; residents occupying these must be able to negotiate small flights of stairs. Gardens areas are easily accessible to all residents, garden areas are mature and well maintained with peacocks and fowl roaming freely. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted during the day from 7:45 am until 3:30 pm. During this time the inspector spent time with the qualified staff, care staff and the housekeeper and kitchen staff. Ten residents were spoken to through the duration of the inspection. The Management areas were not assessed during this inspection as the manager and administrator were unavailable and some records could not be accessed. The inspector also spoke to the deputy manager and briefly to a visiting district nurse. On arrival residents were being assisted to get up for breakfast, and it was seen that the residents were given a choice of breakfast and assisted with eating where needed. Overall Cow Lees House was found to require decorating and replacement of carpets and soft furnishings in some areas was required. Astley House is purpose built and new; here there are minor repairs to window catches, door locks and skirting boards. Cow Lees House was found to be dirty and requires a deep clean especially in hard to reach areas. All the woodwork around the windows and doors was also found to be in need of attention. What the service does well: What has improved since the last inspection? The home have made a number of improvements since the last inspection: COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 6 The screening in the shared room in Cow Lees House have been modified and changed to give more privacy to the residents. Some staff have received training in the Protection of Vulnerable Adults, and the remaining care staff are due to completed their training by the end of August 2005. The home has purchased three heated trolleys to transport food to the units. The administration of medicines has improved and the qualified staff are aware of ‘covert medication’ and the residents right to refuse medication if they so choose. The kitchen has been re-tiled and further work is being carried out to bring this area up to date. What they could do better: There are a number of areas that require attention, some of these are outstanding from the last inspection and need immediate attention by the registered provider and the manager. • • • • The registered provider must ensure that there is a suitable residents’ Guide to the home, its facilities and what is supplied by the home. The care planning is poor and the home must ensure that the care required by the residents is clearly recorded and evaluated on a monthly basis. The home must be able to demonstrate that the residents and/or their relatives have been involved with the process of care planning and reviewing care. There is a lack of detail with the personal care and hygiene of the residents; the staff must take more care to ensure that glasses are clean, hearing aids are properly fitted and that hands and chins are clean. There are no care plans to ensure that prevention of harm through pressure damage, malnutrition or falls occurs. The residents are not weighted regularly and it is suggested that this may result in staff not recognising gradual weight loss and the resident suffering harm from malnutrition. The home must ensure that the temperature of the fridge used for eye drops and other minor medicines is checked daily to ensure that the temperature is correct. The windows must be cleaned. The home requires a full deep clean, especially Cow Lees House. The balustrades and other hard to reach areas must be cleaned. Lighting in corridors and bedrooms must be suitable to prevent accidents and injuries to the residents and the staff. • • • • • • COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 7 • • • Redecoration and refurbishment of Cow Lees is required, especially the window frames here the paint is pealing and the wood has become bear. In places it was seen that the wood is rotten. The registered provider should consider a further washing machine to assist the laundry person to launder all the laundry for the residents and the home. The laundry areas require finishing, decorating, cleaning and generally organising. 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. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 5 Prospective residents do not have the information they need to an informed choice about where they live reducing their right to choose. All residents have suitable contracts of residency and are informed of their rights. Families and representatives assess the quality, facilities and suitability of the home ensuring that there is a choice of where the resident lives. EVIDENCE: It was noted that there is no Resident Guide available at the time of the inspection in the home. At this time prospective residents and their relatives would not be able to have any written information about the home and the facilities available. It was seen in the residents’ files that they are issued with a contract from the social service department if they receive funding and all residents are given a contract of residency by the home. These contain suitable information and would enable the residents and their families to decide if they wished to remain at the home. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 10 Families and the residents’ representatives are invited to visit. Residents generally do not visit the home prior to admission. If they decide that the home is suitable then the resident is admitted and a review is held six weeks later to determine if the home is meeting the resident’s needs and the resident is happy to remain at the home. The manager informed that this period could be extended if all involved felt this necessary. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10, The residents’ health, personal and social care needs are not fully met and poorly set out in individual plans of care; this could result in an oversight of care resulting in possible harm. Residents are protected by the homes’ policies and procedures for dealing with medicines. The residents’ privacy is respected at all times, however their dignity is at times not respected which could result in a reduced sense of self worth. EVIDENCE: Six residents profiles were seen and the care plans were examined. These did not describe clearly the complex needs of the residents. There were care plans for basic hygiene needs and mobility, however, there were no care plans to deal with the mental health of the residents. One resident appeared very confused and was repetitive in their speech, there was no care plan and the staff response to this resident was not appropriate at times. The care plans were not evaluated on a monthly basis and it was difficult to track how the staff decided on the care needs of the residents. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 12 The residents or their representatives did not sign the care plans and there were no reviews including them. This could result in poor care provision and a lack of understanding of the needs of the resident. The home has a general risk assessment covering all activities of daily life; these are completed for all residents. There are no specific care plans that deal with specific risks identified. The home also carries out risk assessment for pressure damage. Where a risk is identified no preventative care plans to direct the staff were written. Nutritional risk assessments are completed inconsistently and residents are weighed ad-hoc. It was also noted that residents are sometimes weighed in stones and sometimes in kilograms. This could result in weight loss not being recognised. There are no psychological assessments and as the residents have dementia the staff may not recognise changes in mental health. One resident had bandaged legs, these were rolled down their legs and tights had been put on top. This could result in swelling and discomfort resulting is further skin damage. The general care of the residents lacked detail, on resident spoken to had very dirty glasses, the inspector cleaned these and the resident stated that she could see better. Another resident was seen strapped into a wheel chair with a strap, there were no risk assessments or care plans seen. As this practice is not monitored or continually assessed there is a risk that it could result in abusive behaviour. The medication ordering, storage and administration was checked in both parts of the home. This met with good practice guidelines. The fridge for eye drops and other medicines is not checked to ensure that it is at the right temperature; this could result in the effect of the medicine being affected. All personal care and consultations are conducted in private. Some residents were seen with dirty glasses, with food around their mouths and dirty hands and fingernails. Female residents were seen with laddered and holey tights. Three residents spoken to stated that they were happy in the home, two further residents stated that they did not like living at the home, stating that the staff did not care for them and they felt lonely. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15 Residents maintain contact with family and friends ensuring that relationships are maintained therefore increasing the residents self esteem. The residents are encouraged and assisted to exercise choice and control over their life. The residents are given a wholesome and appealing diet, the surroundings are varied and may have a positive or negative effect on the residents well being. EVIDENCE: Through discussion with staff it was confirmed that relatives may visit at any time and can go to the residents own room or other communal areas in the home if they wish. The home does not restrict visiting and supports residents to see whom they wish. The home does not manage residents monies and extra expenditure is invoiced at the end of each month to the resident or their representative. There is information available in the home related to advocacy services, their role and how they can be contacted. While touring both parts of the home it was noted that the residents are assisted by their families to personalise their own rooms with personal items such as pictures, ornaments and photographs. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 14 The kitchen is situated in an outhouse and supplies food for both areas of the home. Food is delivered to the dining areas in heated food trolleys and served by the staff. The inspector saw breakfast and the main meal of the day. The residents are given a choice at each of these meals, which were seen and tasted by the inspector. The residents were offered fish, chips, mashed potatoes and mushy peas for lunch or chicken curry. The chips and fish were very dry and had little taste; the curry was very fruity and the rice was fine. It was noted that the staff assisted residents in a quite manner and encourage them to maintain their independence where possible. The kitchen was visited and it was found to be organised and tidy. The owner had recently carried out some work required by environmental health and this is ongoing. The cleaning schedules were examined and the staff ensure that all areas are cleaned as required, however, new paper work is being developed and this will be seen at the next inspection. It was good to see a list of residents likes, dislikes and needs available in the kitchen. The cook informed that special diets can be catered for and that they will always make separate meals if the resident requested this. The menus are available in written and picture format these were seen on the units. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17, 18 Residents’ legal rights are protected ensuring that they are protected from abuse. Residents are protected from abuse by the homes’ robust policies, procedures and staff training. EVIDENCE: Through discussion and records it was established that residents rights are protected by family involvement and where this is not possible an advocate is used. Residents are given the opportunity to vote if they wish, they may either use postal voting or visit the polling station. The homes’ policies and procedures related to the protection of vulnerable adults are good and covers both local and national guidelines. The home also has a suitable Whistle Blowing Policy. It was seen that some staff have received training in the recognition of abuse and actions that should be taken. The remaining staff are booked to attend training in July. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 23, 24, 25, 26 As there are two separate buildings accommodating the residents this part of the report is divide to ensure that a clear picture of the two separate areas can be easily determined. Cow Lees House and Astley House Cow Lees House Residents have access to a safe and comfortable environment that requires up dating and some refurbishment to increase the their quality of life. The bedrooms are varied and to access some residents need to be mobile. The bedrooms are safe and comfortable increasing the residents’ quality of life. Cow Lees House is unclean in places, and various areas are drab and have unpleasant smells reducing the quality of the residents’ lives. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 17 Astley House Residents have access to a safe and comfortable environment that requires some repairs to maintain the residents quality of life. The bedrooms are safe and comfortable with the residents’ personal belongings maintaining their quality of life. Astley House is generally clean, tidy and hygienic. EVIDENCE: The inspector toured both areas of the site and it was found that there is a distinctive difference in the homes. Cow Lees House is a converted large Victorian residence and has a number of areas of concern. Astley House is purpose built and meets the standards; there are some minor issues in this area. Below is a detailed description of the tour of the separate areas: Cow Lees House Cow Lees House has two lounge areas, large reception areas with the stairs leading to the first floor and a large dining area. The middle lounge is in need of redecorating and it was noted that the original skirting boards are rotting in places. The dining room was cold and it was noticed that the windows were open during breakfast. The skirting under the main window in the dining room is rotting and in places coming away from the wall. The top windows are very dirty and the housekeeper stated that they are not allowed to clean anything about head height. The dining area was also very sparse and dreary. The main lounge area has windows to two walls that look out onto the extensive gardens these also required cleaning. The large reception area was cosy and a number of residents were seen sitting in this area. All the windows on Cow Lees House require re-painting, from the outside it was noted that the paint is pealing. The home requires in depth cleaning, the balustrades on the stairs and landing are very dusty, the housekeeper is unable to reach them. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 18 A number of bedrooms were viewed during the tour and it was found that they are suitably decorated and there is evidence that the residents are encouraged to personalise their own spaces. It was noted that not all rooms had a lockable space for the resident to lock personal belonging. The carpets in the corridors and some of the bedrooms require changing, as they are old and worn in places. The lighting is very dim in the corridors and bedrooms due to the use of energy saving bulbs; this could result in the occurrence of accidents and injury. All bedrooms doors are fitted with locks, the residents do not have keys to these, through discussion with staff it was noted that the residents either do not wish to have a key or they are unable to manage a key to their room. This is not recorded. Astley House Astley house is purpose built and has under floor heating that is controlled by thermostats throughout the home. The windows are low level and residents have a view of the grounds while sitting. All the bedrooms are en-suite and pleasantly decorated. The lighting is dim in some areas due to low energy bulbs and this could result in accidents and injury to residents. There are personal locked facilities in all bedrooms and it was seen that the residents are encouraged to personalise their own rooms. There are two floors; each has a dining area, lounge and a number of bedrooms. There is also a small room on the first floor, this does not have any windows and the staff are unsure of its use. The lock to the door was broken. The furnishings were seen to be appropriate in all areas of Astley House and the communal areas felt it was cheerful and comfortable. It was noted that the overall cleanliness needed attention as areas appeared dusty. A number of window catches and locks to the residents’ rooms were damaged or broken, and the skirting on the stairs was loose. There is a conservatory to the side of the home, this was sparsely furnished and was not inviting, the garden leading from the conservatory was untidy and overgrown and the fencing had not been completed. The residents are therefore unable to use this area as they may wander out of the homes’ grounds. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 19 Laundry and Infection Control The laundry is situated in an out building. There are three main areas, a) houses the washing machine, b) houses the tumble drier and c) storage of clean clothes, ironing equipment and other items. These areas are very poorly maintained, the doorway to the tumble drier requires plastering and re decorating, the lighting is also very poor. The lighting in the corridor requires attention, one of the two lights was not working and this made the corridor dim. These areas were also not very clean and dust was seen everywhere. There is only one washing machine and it is questionable that this is adequate to meet the needs of the home. There was a hand washbasin available in the laundry and there are adequate infection control policies and procedures available for the staff. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 Staff are trained and competent to their jobs and the residents are therefore protected from harm. EVIDENCE: All new staff have a full induction into the home and care practices, these were seen and found to be appropriate. Once staff have completed their induction they are encouraged to register to start a National Vocational Qualification in Care at level 2 or 3. Other areas related to staffing were not assessed at this time; a full assessment will take place at the next inspection. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these areas were inspected, as the manager and the administrator were not available on this day. There fore information required could not be accessed. EVIDENCE: COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 2 x x 2 2 2 2 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 x x x x x x x x COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5, 6, 16 Schedule 4 Requirement Timescale for action 30.09.05 2. OP7 3. OP7 4. OP7 5. OP8 6. OP8 The registered provider must ensure that there is a suitable Residents Guide available to be given to prospective residents and their families. 15 The registered provider and the Schedule manager must ensure that the 3(1)(b) care plans written reflect the complex needs of the residents 15(2)(b)(c The manager must ensure that ) all care prescribed is evaluated monthly and records are Schedule 3(1)(b) maintained that are available for inspection. 15(1)(2)( Where feasible the manager a)(c)(d) must involve the residents and/or their relatives in the care Schedule 3(1)(b) planning and process. Records of the residents/ family involvement must be available for inspection. 14, 15, 17 The registered provider and Schedule manager must ensure that full 3 and 4 assessments for pressure damage, nutritin and falls is conducted monthly. 15 Where a risk has been identified Schedule the manager must ensure that 3(1)(b) the qualified staff have devised preventive care consulting with the resident and/or their E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc 30.09.05 31.08.05 30.09.05 30.09.05 30.09.05 COW LEES NURSING HOME Version 1.40 Page 24 relatives. 7. OP8 13(1)(b) The registered provider and manager must ensure that all residents have psychological assessments and actionis taken where there are negative changesis mental well being. The manager must ensure that the residents care needs are fully met, and that glassess, hearing aids, repair of clothes and state of dressings are all addressed before coming to the lounge or dining rooms. The garden immediately outside the conservator of Astley House must be tidied and made suitable fort eh residents to use. The registered provider and managermust ensure that bedroom doors and doors to other resident areas are not wedged open, proper door closures must be fitted if the door is required to be left open. The registered provider must ensure that the window framesin Cow Lees House are redecorated and repaired where required. The skirting boards under the window in the dining room of Cow Lees House must be repaired, replaced and redecorated. The minor repairs in Astley House must be completed such as broken window catches, door locks and skirting boards. An Action plan with time scales for the above must be forwarded to the Commission with the providers comments. The registered provider must ensure that all residents have a locked faciltiy in their own rooms. 31.08.05 8. OP10 12(4)(a) 31.08.05 9. OP19 23(2)(o)( n) 24(4)(5) 31.10.05 10. OP19 30.11.05 11. OP19 23(2)(d)( 5) 16(2)(j) 31.12.05 12. OP24 12(4)(a) 13(4)(a)(c) 23(2)(m) 30.11.05 COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 25 13. OP24 23(2)(b) 14. OP25 23(1)(a)( 2)(d)(p) 15. OP26 16(2)(j)(k ) 16. OP26 23(2)(b) 17. OP26 23(1)(a) The registered provider must ensure that the worn carpets in the corridors and some bedrooms at Cow Lees house are replaced. An action plan with time scales must be forwarded to the COmmission. The registered provider and the manager must ensure that the lighting in all resident areas and the corridors is bright and meets with this standard. The registered provider and manager must ensure that all areas of the home are cleaned to an acceptable standard and that unpleasent smells are dealt with. The registered provider must ensure that the decore in the laundry area is completed and that this area is safe by ensuring that the lighting is bright. The registered provider must ensure that a further washing machineis purchased to meet the needs of laundering in the home. 30.11.05 30.09.05 30.09.05 31.09.05 31.10.05 18. 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 OP22 Good Practice Recommendations Consider the need for nursing/adjustable beds for residents who are immobile, terminally ill or requiring palliative care. COW LEES NURSING HOME E53 S4391 Cow Lees Nursing Home V235575 010705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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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