Inspection on 22/11/05 for Cow Lees Nursing Home

This inspection was carried out on 22nd November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 01/07/05

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 Michelle O`Brien Unannounced Inspection 08:15 22 November 2005 nd 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 Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 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. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cow Lees Nursing Home Address Astley Lane Bedworth Warwickshire CV12 0NF 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) 02476 313794 02476 316750 cowleescarehome@yahoo.co.uk Mr John O`Sullivan Mrs Carole O`Sullivan Margaret Bailey Care Home 52 Category(ies) of Dementia - over 65 years of age (52) registration, with number of places Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st July 2005 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 52 elderly residents with dementia who may require nursing care. The accommodation is provided in two main care areas, 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. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the year (April 2005 – May 2006) and was unannounced. The inspection took place over 2 days between the hours of 8.15am and 4.15 pm on day one and 11.10 am and 5.10 pm on day two. On the days of inspection there were 48 residents being accommodated in the home. The inspector had the opportunity to meet several of the residents and talk to 18 of them and one of their relatives about their experience of the home. General conversation was held with other residents along with observation of working practices and staff interaction with residents. The inspector joined the residents in the music room for their midday meal on day two of the inspection. 8 comment cards were returned to the inspector from relatives of residents. Some of the residents found it difficult to engage in conversation due to their dementia but were able to express their feelings with verbal and non-verbal communication. Policies, procedures and records were examined and the inspector toured the home. The registered manager was present on day two of the inspection. The inspector also had the opportunity to talk to the owner of the home, the deputy manager, two of the trained nursing staff, the activity co-ordinators, cook and two of the care staff who were all were co-operative with the inspection process. What the service does well: The atmosphere in the home is relaxed and staff were observed to communicate well with residents and visitors. Residents look well cared for. Staff are aware of the needs of residents in their care and attentive to their needs. There is a thorough pre admission assessment of residents to identify their needs and ensure the home can meet these needs. Records were found to be maintained and well organised. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: An immediate requirement was issued during the inspection to review the number of registered nurses on duty during the night shift and to ensure the registered manager is supernumerary to ensure an adequate number of staff to meet the needs of residents. Further improvements are necessary in care planning to ensure the plans contain sufficient detail of the actions required to meet the individual needs of residents. Better monitoring of residents’ health needs to be made to ensure their health needs are fully met. The management of residents’ challenging behaviour needs to be improved to ensure the safety and well being of residents. The activity programme in the home needs to be reviewed to ensure that all residents are given the opportunity to be engaged in meaningful activities which will enhance their quality of life. A programme of maintenance and refurbishment needs to be formulated and a copy forwarded to the commission. Better recruitment practice needs to be carried out to ensure the protection of residents. The percentage of care staff with a National Vocational Qualification (NVQ) in care falls below the minimum standard and arrangements need to be made for Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 7 staff to achieve this qualification to ensure that residents are being cared for by competent staff. Although the supervision of care staff has begun it has not been implemented consistently. The registered manager needs to make arrangements for staff to receive supervision every two months. A proactive system for auditing and monitoring working and care practices needs to be in place to maintain, measure and improve the quality of service delivered to residents. 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 DS0000004391.V267186.R01.S.doc Version 5.0 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 Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 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): Standards 1, 3 and 5 were assessed. Prospective residents are provided with information to enable them to make an informed choice about where to live. Residents have their needs fully assessed before admission to the home to ensure that their needs can be met by the home. Potential residents and/or their family are able to visit the home prior to admission offering them the opportunity to make a choice about moving into the home. EVIDENCE: A service user’s guide has been developed and implemented and contains the information necessary for residents to make a choice about moving into the home. However, only one copy of the service user’s guide exists and it was informed that this is shown to prospective residents. It is recommended that more copies of this are produced in order that residents could retain a copy for reference. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 10 He inspector was told that the manager or her deputy visits prospective residents to make an assessment of their needs prior to admission to the home. The care files of 5 residents were examined and all of them contained detailed pre-admission assessment of needs. Documentation examined contained risk assessments for tissue viability, falls, nutrition and a dependency tool is used to give a quantitative measurement of dependency and needs. One relative spoken to described how her mother was visited by the manager before admission to make the assessment of her needs. Admission to the home is based on a 6 week trial and assessment period and at the end of the 6 week period a review takes place to confirm whether the home is suitable for the resident and their needs are being met. Relatives have the opportunity to visit the home prior to the admission of a resident and although prospective residents also have the opportunity to visit this is not often practical due to their medical conditions. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 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 the following standard(s): Standards 7, 8 and 10 were assessed. Residents’ care plans contain insufficient detail of the actions required to meet residents’ needs and are not consistently reviewed which may lead to an oversight of care. Better monitoring of the potential risks to residents’ health is necessary to protect them from harm. There are times when residents’ dignity is not respected which may result in reduced self esteem and well being. EVIDENCE: The care files of 5 residents were examined and the care planning for residents was found to be improved since the last inspection. It was informed that many of the plans are in transition to implement improvements. However, care plans need to be further improved to ensure that staff can use the documents to fully meet the needs of the residents. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 12 In particular, the care plans are disorganised and difficult to follow information contained in the care plans is duplicated, particularly assessments, there are several formats of care plans in use which can be confusing, evaluation of the care plans are not made consistently every month, although risks are identified using risk assessment tools, these do not always generate a care plan, daily statements are kept separately from residents’ individual care plans. Consideration should be made to keeping the daily statements together with individual care plans to demonstrate a holistic approach and ensure the care plan is a ‘working document’, some of the care plans are pre-printed ‘generic’ care plans and care must be taken to ensure that these are personalised for individual residents, care plans are not consistently written for every need identified. It was pleasing to note that reviews of care plans are taking place with staff involving relatives and residents. It was informed that 16 out of 24 of these reviews had taken place in Astley House. On both days of inspection the residents in both Cow Lees House and Astley House looked well groomed and well cared for. There was evidence in care files to demonstrate the involvement of other health professionals such as GP, chiropodist, dentist, optician, stoma nurse, community psychiatric nurse and psychiatrist in order to meet the health needs of residents. Pressure relieving equipment was available in the home for those residents with an identified need. One of the residents was admitted to the home with a pressure sore and this has improved greatly. Better monitoring of residents’ health needs to be made to ensure their health needs are fully met. There was no record of blood sugar monitoring of one diabetic resident although the care plan indicated this should be done weekly; there was no record of the blood pressure of a hypertensive resident although the care plan indicated this should be done monthly. Residents’ weight was generally well recorded but there was no record of the weight of one resident admitted to the home 6 weeks ago. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 13 The number of incidents of challenging behaviour which manifests as disputes between residents in Astley House suggests that the management of challenging behaviour needs to be reviewed and improved to ensure the safety and well being of residents. A restraining device was observed to be in use for one resident in Cow Lees house and it was informed that this was to prevent falls and was risk assessed and agreed with the relatives, however no documentation was available to support this. Staff were observed to address residents by their preferred names and were respectful of their rights to privacy and dignity when attending to their care needs. However, some the clothes of one resident were being stored inappropriately in a storeroom which contained cleaning chemicals and a sluicing disinfector and this does not promote this resident’s right to dignity. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed. The current arrangements for activities and entertainment are limited and so therefore do not provide adequate recreation or motivation for residents which may result in boredom and low self esteem. Residents are encouraged and supported to maintain contact with their family, friends and local community resulting in supporting their social skills and increase in their mental well being. Meals are well presented, wholesome and provide residents with a nutritious and balanced diet. EVIDENCE: The home benefits from the employment of an activity co-ordinator for approximately 20 hours each week and she is assisted by another person for 5 hours each week. The activity programme in the home includes skittles, ball games, hand massage, darts and quizzes. On both days of the inspection the residents in Cow Lees House very much enjoyed participating in a music practice for their Christmas concert. On the first day of inspection the activity co-ordinator assisted residents to and from the conservatory area to attend the hairdresser who was visiting the home that day. The female residents in Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 15 particular commented on how much they enjoyed having their ‘hair done’ and it was very much a social occasion which increased their self esteem. It was noticeable on both days of the inspection that there was more meaningful activity to engage residents in Cow Lees House than there was in Astley House although the overall dependency of each house group is similar. The atmosphere in Cow Lees House provides a stimulating environment for residents with dementia while the residents in Astley House seemed to be bored and not occupied in any meaningful or stimulating activity. The relative of one resident in Astley House commented that ‘someone to talk to’ would be beneficial for residents even if residents ‘were not always lucid’. The care files of residents documented little history of residents interests and hobbies prior to their admission to the home which would be necessary to ensure the activities planned relate to the interests and hobbies of the residents. The home has an ‘open visiting’ policy and residents were observed to receive their visitors both in the privacy of their rooms or in the communal lounges and relatives were made welcome by staff. The local community is to be invited to attend the residents’ Christmas Concert. The residents of Cow Lees House were observed to move around the home freely and safely and bedroom doors are unlocked but during the tour of Astley House it was observed that the doors to residents’ bedrooms are locked with staff members holding the keys so if a resident wanted to go to their room it would be necessary to ask a member of staff. This demonstrates a lack of choice and opportunity for these residents. The inspector was present during breakfast and lunch service in Astley House on the first day of inspection and joined residents in the music room in Cow Lees House for their two course lunch on the second day of inspection. The meal of gammon and white sauce, peas and cauliflower was followed by home made chocolate éclairs. The meal was well presented, nutritious and tasty. Residents at the table made positive comments about the food provided for them and talked about having choices of meals. Staff gave discreet assistance to residents who required it and the use of aids to independence such as plate guards were available and used for residents. The inspector visited the kitchen and talked with the cook. Menus were examined and these reflected the likes and dislikes of residents. There was plenty of good quality produce available in the kitchen stores. It was informed that staff have access to the kitchen 24 hours a day if residents request a snack at night. Cleaning records and fridge temperature records were examined and found to be maintained. The kitchen was clean, well organised and has had improvements made to it in response to the Environmental Health Officer’s visit in May 2005. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 was assessed. The Complaint’s procedure for the home needs to be reviewed so that residents and their families can be confident that their concerns will be heard and acted upon. EVIDENCE: The complaints procedure for the home is accessible to residents and visitors but needs to be updated to reflect that residents or their representatives can approach the commission at any time with concerns or complaints. It was evidenced through the examination of records and discussion that the manager responds appropriately to complaints so that residents or their representatives can be confident that their worries will be listened to, taken seriously and acted upon. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 25 and 26 were assessed. The home mostly provides safe and comfortable surroundings for residents to live in but the unpleasant odours in parts of the home need to be eliminated and some refurbishments are necessary to promote a positive experience of quality of life for residents. EVIDENCE: The inspector was accompanied by the deputy manager during a tour of the home. The majority of bedrooms were seen and these were found to be comfortable and personalised with residents’ own belongings. Astley House benefits from being recently purposed built and was very bright and spacious but some parts, such as the dining areas, appeared sparse, bare and uninviting. Cow Lees House is a converted building which has a more cosy atmosphere. However, Cow Lees House was dimly lit which may increase the risk of accidents, several carpets were worn and the dining area was also sparse and uninviting. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 18 There are several outstanding requirements from the last inspection related to premises and a copy of the maintenance report has yet to be received by the commission. The inspector visited the laundry room talked to laundry staff who explained their procedures which confirmed that there are systems in place for the management of dirty laundry. Protective clothing such as plastic gloves and aprons were available and arrangements are in place for the disposal of waste. On the inspector’s arrival at the home on both days there was unpleasant odours evident in communal areas and in some of the resident’s bedrooms. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed. There are insufficient trained nurses on night duty which puts residents at risks of not having their needs met. More of the care staff need to achieve a National Vocational Qualification (NVQ) in Care at level 2 or above to ensure that residents are in safe hands at all times. Recruitment practices are insufficient to ensure the protection of residents. Staff were observed to be competent to do their jobs and have planned training which results in appropriate care being given and an increase in the quality of life for residents. EVIDENCE: Four weeks of the staff duty rota was examined and it confirmed that the usual staffing establishment for the home is: 8am – 8pm 8pm – 8am 2 Registered Nurses and 8 care staff 1 Registered Nurse and 5 care staff The registered manager has 1 or 2 days each week supernumerary and works the remainder of her contractual hours covering nursing shifts. The deputy manager has 1 day each week supernumerary. There were sufficient staff on duty to meet the needs of residents during the day shift but not sufficient Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 20 registered nurses on duty during the night shift to adequately meet the needs of residents during the night in view of the geography of the home and it being split into two separate buildings An immediate requirement was issued to: review the provision of registered nurses on the night shift to increase it to 2 registered nurses on duty review the supernumerary time for the registered manager to increase it to 35hrs per week in order that she can sufficiently discharge her responsibilities to manage the home effectively. These requirements were received positively and discussed with the registered manager and the owner of the home at the time of inspection and they took immediate action to begin reviewing the staffing levels in the home. It was informed that 3 out of the 40 care staff employed have a National Vocational Qualification (NVQ) in Care at level 2 or above which, at 8 , falls well below the minimum requirement for 50 of staff to be qualified. The files for two members of staff were examined and did not contain evidence that CRB (Criminal Record Bureau) and PoVA (Protection of Vulnerable Adults) checks are made before staff commence employment. The home has a satisfactory induction programme for new staff. 27 staff completed training in dementia care, ‘Yesterday, Today and Tomorrow’, accredited by the Alzheimer’s Society. Staff have received ‘in-house’ Training in challenging behaviour, teamwork and communication. External courses attended by staff have included tissue viability, bladder and bowel dysfunction, cross infection and pastoral care. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36, 37 and 38 were assessed. The home has a dedicated manager and effective manager who needs to have more supernumerary time in order to direct and guide staff to ensure residents receive consistent quality care. The home has no method of monitoring the quality of service that the residents receive which makes it potentially difficult to maintain and improve standards. Procedures are in place to manage residents’ monies and valuables so their interests are safeguarded. Although some staff have received supervision to ensure they are providing effective care this is not consistently planned and implemented for all staff which increases the risk of harm to residents. The health, safety and welfare of residents is promoted but this could be improved by further staff training. Records, policies and procedures are adequately kept to safeguard resident’s interests. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 22 EVIDENCE: The registered manager is a registered nurse and is experienced in the care of elderly people with dementia. She is undertaking the Registered Manager’s Award (NVQ 4). An immediate requirement was made to review the supernumerary time for the registered manager and increase it to 35hrs per week in order that she can sufficiently discharge her responsibilities to manage the home effectively. There are clear lines of accountability within the home and a well defined management structure. Staff spoken too expressed that they felt management were approachable. The registered manager was unable to demonstrate any method of auditing working practice to monitor standards or enabling residents to express their views. There was no evidence that the views of service users had been sought through surveys or meetings in order that their opinions may be taken into consideration in the running of the home. The home does not retain the personal monies of residents for safekeeping, this is the responsibility of their relatives or appointee. Expenditure such as hairdressing, chiropody or outings is paid for in the first instance by the owner and residents are then sent a bill. The process of supervising care staff has begun but is still inconsistent and not in any regular pattern. Staff need to have formal supervision six times a year to ensure that their development needs are met and that residents are cared for by competent staff. The inspector discussed with the manager how this could be achieved by delegating some of the task of supervision to senior staff. Records are well maintained within the home and the administrator was very organised. The commission receives regular notifications about events in the home. Records were examined to establish safe working practices within the home and these included contracts and servicing documentation for electrical equipment, clinical waste and all other services supplied to the home. Resident aids and equipment have also been serviced, this includes hoists and baths and maintenance work is up to date. Fire records and electrical tests are up to date and the lifts have been serviced and are currently in good working order. Mandatory staff training includes fire safety, protection of vulnerable adults and manual handling. Mandatory training needs to be reviewed to include COSHH (Control of Substances Hazardous to Health) and Food Hygiene Training for all staff involved in food handling – this includes care staff serving food and drinks. Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 X X X X X 2 2 STAFFING Standard No Score 27 1 28 1 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 1 X 3 2 3 2 Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 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 OP27OP31 Regulation 18 Requirement The registered provider must, having regard to the size of the care home, the statement of purpose and the number and needs of the service users, ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users, and The registered provider must review the provision of registered nurses on the night shift to increase it to 2 registered nurses on duty. (immediate requirement) The registered provider must review the supernumerary time for the registered manager to increase it to 35hrs per week in order that she can sufficiently discharge her responsibilities to manage the home effectively. (immediate requirement) Timescale for action 22/11/05 Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 25 2 OP7 15 Schedule3 3 OP8 12, 13 The registered manager must 31/01/06 ensure that care plans set out in detail the actions needed to be carried out by care staff to ensure all aspects of the health; personal and social care needs of the service user are met. The registered manager must 31/01/06 ensure that risk assessments are consistently carried out and implemented for all residents and an appropriate plan of care developed. The registered manager must ensure that residents’ health is monitored with regard to weight, blood pressure and blood sugar as is appropriate for their medical condition. The registered manager must ensure that the dignity of residents is upheld at all times. The registered manager must ensure that there are organised activities accessible to all residents in the home. The registered manager must ensure that the wishes and preferences of residents are recorded to demonstrate that residents are being offered choice and the opportunity to exercise some control over their lives. The registered person must ensure that the complaints procedure for the home is reviewed, updated and made accessible to residents and visitors. The registered person must submit an action plan to the commission detailing planned refurbishment as identified within the last inspection report. This is outstanding from the 4 5 OP10 OP12 12 16 31/01/06 28/02/06 6 OP14 12 31/01/06 7 OP16 22 31/01/06 8 OP19 13, 23 31/01/06 Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 26 9 OP24 16, 23 previous inspection and requires urgent attention The registered provider must 31/01/06 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. This is outstanding from the previous inspection and requires urgent attention 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. This is outstanding from the previous inspection and requires urgent attention The registered provider and manager must ensure that all unpleasant smells are dealt with. The registered person must confirm arrangements to ensure at least 50 of care staff achieve an NVQ II in Care as soon as possible. A list of all care staff undertaking this training is to be forwarded with dates for training to be completed. The registered person must ensure that staff files contain evidence that appropriate checks have been completed through the Criminal Record Bureau (CRB) and the vulnerable adults register (PoVA) prior to staff working in the home. The registered person must implement a suitable quality assurance and monitoring system and outcomes of service users surveys must be made public. The registered manager must DS0000004391.V267186.R01.S.doc 10 OP25 23 31/01/06 11 12 OP26 OP28 12, 13, 16, 23 18 31/01/06 28/02/06 13 OP29 19 schedule2 15/01/06 14 OP33 24 31/03/06 15 OP36 18, 19 31/01/06 Page 27 Cow Lees Nursing Home Version 5.0 16 OP38 12, 13 ensure that all nursing and care staff receive supervision six times a year. All staff must receive COSHH training and staff involved in handling food and drink must attend food hygiene training. 28/02/06 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 OP1 Good Practice Recommendations Copies should be made of the statement of purpose and service user’s guide so that these may be given to prospective and existing residents and their representatives. Consideration should be given to keeping records of daily statements about residents within their individual care files in order to demonstrate a holistic approach to the care of residents and make the individual care files a ‘working document’. 2 OP7 Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Leamington Spa Office 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. Extracts may not be used or reproduced without the express permission of CSCI Cow Lees Nursing Home DS0000004391.V267186.R01.S.doc Version 5.0 Page 29 - 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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