Inspection on 04/04/06 for Denham Manor Nursing Home

This inspection was carried out on 4th April 2006.

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

Denham Manor Nursing Home 27/10/08

Denham Manor Nursing Home 26/11/07

Denham Manor Nursing Home 11/07/07

Denham Manor Nursing Home 05/09/05

Denham Manor Nursing Home 02/06/05

Denham Manor Nursing Home 27/09/04

Denham Manor Nursing Home 28/04/04

Denham Manor Nursing Home 27/04/04

Denham Manor Nursing Home 23/11/03

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Denham Manor Nursing Home Halings Lane Denham Bucks UB9 5DQ Lead Inspector Joan Browne Unannounced Inspection 4th April 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000019195.V287778.R02.S.doc Version 5.1 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. DS0000019195.V287778.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Denham Manor Nursing Home Address Halings Lane Denham Bucks UB9 5DQ 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) 01895 834470 County & Suburban Care Limited Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (53) of places DS0000019195.V287778.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Comprising a maximum of 43 nursing care and a maximum of 10 receiving personal care Date of last inspection 5th September 2005 Brief Description of the Service: Denham Manor is a care home providing nursing and accommodation for up to 53 service users. County and Suburban Care Limited owns the home, which is a private limited company. The home is situated in a pleasant but relatively isolated country lane on the outskirts of Denham. Public transport and other amenities are not easily accessible. The home was registered in 1988 and consists of a two-storey building, with three conservatories. The home has forty single and three shared bedrooms. Some bedrooms have en suite facilities. There is a passenger lift. The home has extensive gardens, which are well maintained. The current scale of charges at the time of writing this report range from £650.00 to £750.00 DS0000019195.V287778.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 4 April 2006. The lead inspector was Ms Joan Browne who was accompanied by Mr Mike Murphy (Inspector). Records, policies and procedures were examined and staff’s practices were observed. Residents and staff were spoken to. A tour of the building was carried out. A pre-inspection questionnaire and comment cards were forwarded to the home in advance of the inspection. At the time of writing this report the Commission was in receipt of comment cards from two residents, three relatives, two health and social care professionals and two general practitioners. Relatives felt that there was an improvement in the provision of care. However, they were not confident that there are always sufficient numbers of staff on duty to meet residents’ needs. They were also disappointed to note that ‘the acting head of care had been moved at short notice’. These concerns were passed on to the manager. Overall comments from the health care professionals and the general practitioners were positive. They felt that the home had improved considerably over the past few months and the home was now providing a range of care that meets the needs of the residents. Comments from residents spoken to during the inspection were mixed. Some said that they were ‘happy with the provision of care and that they had no complaints.’ Others were not very happy and felt that more staff were needed. There concerns were passed on to the manager to be addressed. Overall residents felt that staff treated them well, and respected their privacy. The manager and area manager were given feedback on the out-come of the inspection. What the service does well: The home has a flexible visiting policy. At the time of the inspection interaction between staff and residents was good. The home has developed good working relationships with the general practitioner and other health care professionals. The home has student nurses on placement from the local college. The gardens and grounds are well maintained. There are risk assessments that outline residents’ assessed vulnerabilities. An independent DS0000019195.V287778.R02.S.doc Version 5.1 Page 6 advocate visits the home. Residents are able to participate in the civic process. Staff training is current. Methods for measuring quality assurance are in place. What has improved since the last inspection? 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. DS0000019195.V287778.R02.S.doc Version 5.1 Page 7 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 DS0000019195.V287778.R02.S.doc Version 5.1 Page 8 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are assessed before admission to the home. Assessment forms seen were comprehensive however, all sections on the form was not completed fully, thus information relating to residents’ next of kin, religion and ethnicity was not always evident. EVIDENCE: Prospective residents are assessed by a senior nurse, most often by the manager or head of care. Assessment forms were comprehensive although in all of the files examined some sections of the forms had not been fully completed. Separate risk assessment forms were in place for falls, tissue viability, nutrition and moving and handling. A care plan based on the outcome of the assessment is drawn up by a registered nurse. In the care records examined care plans were detailed and addressed identified needs. DS0000019195.V287778.R02.S.doc Version 5.1 Page 9 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 adequate. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to ensure that residents health and personal care needs were being met. However, the daily progress records need to include relevant aspects of the care plan. Staffs poor recording practice in the administration of medication has the potential to put residents’ health and welfare at risk. EVIDENCE: A care plan is in place for each resident. Four care plan files were examined and they contained detailed information which covered a range of assessed needs. It was evident that care plans and other assessments were reviewed monthly. Residents’ weights were monitored weekly. However, the process of the review for care plans was not recorded. For example, plans examined had recorded ‘no change to the plan of care’. Daily progress reports did not include references to the care plan. Some daily reports referred to residents’ participation in activities, their interaction with staff and mood. The manager is to introduce changes to care records in the near future which aim to ensure that daily progress records will include relevant aspects of the care plan. DS0000019195.V287778.R02.S.doc Version 5.1 Page 10 Arrangements were in place to maintain residents’ health care needs. The home has received a lot of support from other health care professionals such as, the tissue viability nurse, the dietician and the community physiotherapist. Those health care professionals who completed comment cards felt that overall residents’ health care needs were being met satisfactorily. The manager stated that those residents who were prone to falls had been referred to the local falls clinic. Residents are registered with a general practitioner (GP) who visits the home twice weekly. They have access to National Health Services via a referal from the GP. The medication administration record (MAR) sheets were examined and several gaps were noted. Staff were not being consistent and using the appropriate code to denote the reason for omission. Not all handwritten entries recorded on MAR sheets were countersigned by the general practitoner. Duplication of MAR sheets were noted which may have contributed to errors in staff’s recording practice. It was noted that instructions recorded on MAR sheets for some prescribed medication such as creams were recorded as ‘apply as directed’. This is not a good practice. Instructions should indicate the frequency of application such as, once or twice daily and the area where it should be applied. Some residents were self-administering their own medication such as inhalers. This information was not indicated on the MAR sheets and made it look like residents were not receiving their prescribed medication. Scribbled over entries were noted on some MAR sheets. Inconsistencies in staff’s practice were noted. For example, when antibiotic treatment had been completed or other medication stopped by the general practitioner not all staff were dating and signing the entries. It was noted that there was no lockable storage faciltiy provided in a particular resident’s bedroom who self-medicates to store the prescribed medication. However, a risk assessment was in place. A requirement is being made for a lockable facility to be provided in the individual’s bedroom. Evidence was in place to indicate that the MAR sheets were audited monthly. Nurses spoken to confirmed that their competencies in administration of medication had been assessed. It is acknowledged that the area manager responded immediately to address the weaknesses in staff’s recording practice. An action plan was put in place to increase the frequency of the auditing of MAR sheets from monthly to weekly. Residents spoken to confirmed that staff respected their privacy and dignity. Staff were observed interacting appropriately with residents and addressing them by their preferred term of address. Residents wore matching attire with attention to detail. Information relating to residents’ choice was recorded in the care plans examined. DS0000019195.V287778.R02.S.doc Version 5.1 Page 11 Staff confirmed that during their induction training it was emphasised that residents’ privacy and dignity should be respected. Residents spoken to confirmed that staff respect their privacy and dignity. Staff were observed assisting residents with toileting in a sensitive manner. DS0000019195.V287778.R02.S.doc Version 5.1 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 the service. Arrangements are in place to ensure that residents social and recreational needs are met. Residents are given the opportunity to be supported by an advocate. The presentation and quality of the food was of a good standard to ensure that residents receive a nutritious diet. Efforts were being made to meet the cultural/dietary needs of one particular resident. EVIDENCE: The home’s activity organiser had been off on extended leave for some time. However, a part-time activity organiser was recently appointed a few days before this inspection and was being inducted into her role. There was evidence that in the absence of the activity organiser some activities were taking place. A Polish afternoon was recently organised. The home received thank you cards from those relatives who enjoyed the event and they were displayed in the home. The home celebrated ‘Mothering Sunday’. Two singers entertained residents. Arrangements were being made for further entertainment to take place over the Easter period and for more cultural events to be organised. DS0000019195.V287778.R02.S.doc Version 5.1 Page 13 There are no restrictions on visiting. Residents confirmed that their relatives and friends are able to visit at anytime within reason and are made to feel welcome by staff. An advocate from Age Concern visits the home every four weeks and meets residents individually and in a group. He is also contactable at other times. Residents spoken to felt very supported by the advocate and it was evident that he ensures that their views are passed on to senior managers and acted on. A session had taken place on the afternoon of the inspection and the advocate spoke to inspectors afterwards. He was complimentary on the effort that was being made by the manager to ensure that residents receive a quality service. The serving of lunch was observed and seemed to be a relaxed occasion with background music which was age appropriate. Tables were covered with tablecloths with appropriate cutlery and condiments. Plate guards and other specialist cutlery and protective clothing were in place to support those residents who needed assistance and to promote independence. Choices on the menu were shepherds pie, vegetarian stir fry, cauliflower and swede. Dessert was rice pudding or icecream. Staff offered assistance to those residents who required feeding in a sensistive and discrete manner. The chef confirmed that twice a week he provides a particular resident with cultural meals. Residents spoken to confirmed that the meals provided were sufficient and of a high standard. DS0000019195.V287778.R02.S.doc Version 5.1 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 the service. The home has a clear complaints policy in place to ensure that residents and relatives are listened to. Policies and procedures are in place to protect residents from abuse and staff undertake regular training. EVIDENCE: The homes complaints policy was reviewed in February 2005. Leaflets relating to the home’s complaints procedure were displayed in the home. The policy includes timescales for response and information that a complainant may refer the matter to the Commission for Social Care Inspection at any stage. Records of complaints are retained and monitored by managers. It was noted that there had been a reduction in the number of complaints received by the home. Since the last inspection the Commission for Social Care Inspecion Inspection had received one formal complaint. This was addressed appropriately by the home’s regional manager. No allegations of abuse had been reported. The majority of residents spoken to during the inspection were happy with the provision of care and said that they had no complaints. The organisation has a policy on the protection of vulnerable adults. The policy folder contained copies of power point slides from a recent presentation in Buckinghamshire. Staff have attended training sessions run by social services and by the organisation. Four training sessions are offered over the course of a year. The home’s whistle blowing policy includes the contact numbers of a senior manager within the organisation and the local Careline confidential reporting system. Staff spoken to confirmed that they had undertaken training DS0000019195.V287778.R02.S.doc Version 5.1 Page 15 in abuse awareness. They also confirmed that they would report any suspected abuse to their line manager. They were confident that such reports would be dealt with appropriately. Staff training in challenging behaviour is addressed in training on dementia. DS0000019195.V287778.R02.S.doc Version 5.1 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. Ongoing maintenance work to improve the appearance of the premises was taking place to create a comforatable and safe environment for residents living there. Regular room checks and an ongoing programme of replacing worn furniture such as dressing tables and bed side lockers with ones of good quality is needed within the home, thus ensuring that furniture provided in residents’ bedrooms is of a satisfactory condition and residents’ bedrooms are tidy. EVIDENCE: Work was in progress to address the outstanding maintenance issues from previous inspections. The provider informed the Commission in writing that the work would be undertaken in three phases. The first phase of the maintenance plan, which was to replace the wallpaper in the corridors on the ground and first floor had been completed. Work had commenced on the DS0000019195.V287778.R02.S.doc Version 5.1 Page 17 second phase, which was to repair the roof. The third phase of the maintenance plan will be to replace several windows. The grounds were tidy and accessible to residents. It was noted that one particular resident that is a wheelchair user was able to spend time relaxing in the garden independently. All requirements made at the last fire inspection had been actioned. During a tour of the building the following maintenance issues were identified as needing attention: • • • • • • • • • • The extractor fan in toilet 19 was not working and needs to be repaired or replaced Bedroom 3- the beading on the dressing table was loose and needs to be made secure The radiator cover in the main lounge was loose and must be made secure Bedroom 100- the tiles over the wash hand basin were lifting and must be made secure Staff toilet on the first floor- the walls were tired and worn in appearance and must be repainted Fluorescent ceiling lights in areas of the building contained dead insects and must be cleaned Bedroom 126 the bedside locker looked worn and must be replaced Bedroom 203 the floor covering in the en suite was worn and must be replaced Ground floor sluice room- the cover on the ceiling lights was missing and must be replaced The flaking paintwork in the ceiling in the general kitchen must be stripped and repainted It is acknowledged that some bedrooms had been refurbished. However, staff were not proactive in ensuring that rooms were kept tidy. It was noted that cot side covers were left on the floor. Some pillows were mis-shaped. The manager stated that new pillows and sheets had been ordered. Since the appointment of the housekeeper supervisor there has been an improvement in the cleanliness of the premises. On the day of the inspection the home was clean, bright and pleasant. There were no odours detected in the communal areas. However, in one particular bedroom there was a slight odour. The domestic supervisor said that there was a daily cleaning programme in place and a special neutraliser was being used to neutralise the odour. If the odour persists the carpet will need to be replaced. The standard of hygiene in the laundry room had improved. The floor and walls were clean and free from dust. Washing machines provided were fitted with the specified programming ability to meet disinfection standards. It was noted that a new tumble dryer had been purchased. DS0000019195.V287778.R02.S.doc Version 5.1 Page 18 Staff spoken to were aware of the home’s infection control procedure. The sluice room floor on the first floor was soiled and it appeared that the floor had not been cleaned for sometime. This concern was passed on to the manager to be dealt with and to clarify with nursing and domestic staff who was responsible for the cleanliness of the sluice room floors. DS0000019195.V287778.R02.S.doc Version 5.1 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): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels on the day of the inspection was sufficient thus indicating that residents needs were being met. However, the homes recruitment procedure needs to be strengthened to ensure that residents are not put at risk. EVIDENCE: The manager said that staffing levels had been calculated through the use of a staffing tool, which takes account of residents’ dependency levels. Staffing is sufficient to maintain the following levels: Morning - two registered nurses (RGNS) and six care workers; Afternoon – two registered general nurses (RGNs) and five care workers (one carer starts at 16.00 hours); Night – one registered general nurse (RGN) and three care workers. It was noted that one registered nurse was rostered to work five consecutive nights. Concerns were expressed to the manager It was noted that over a particular week-end the home was not able to sustain the required level of staffing. The home was short by two staff members on both days due to staff illness. The manager stated that several agencies were contacted to provide cover without any success. The home reported the incident to the Commission and completed the appropriate incident report. Domestic cover is maintained from 08.00 to 14.00 hours. A chef and two kitchen assistants provide meals during the week; two kitchen assistants work at weekends. A handyman works between 08.00 and 16.00 hours and is oncall at other times. The home also employs an administrator and a receptionsist. DS0000019195.V287778.R02.S.doc Version 5.1 Page 20 Four staff have acquired National Vocational Qualification (NVQ) at level 2 and three more were pursuing NVQ training at the time of the inspection. Two care staff on maternity leave had acquired NVQ 3. Vacancies are advertised locally, through the agencys own office in Poland or through a recruitment agency. Five staff’s files were examined. All staff completed an application form. One of the five forms examined did not have a column for the applicant to state why they had left a previous position. All of the forms had potentially misleading information relating to Criminal Record Bureau checks. For example, the application form includes a statement relating to CRB less that six months old. This may give the impression that Criminal Record Bureau checks are portable. Since post POVA this is no longer the case. This issue was brought to the regional manager’s attention. She commented that the forms were to be reviewed and likely to be redesigned. All applicants had provided two referees. In some cases the status of references was unclear. References held in the home are photocopies and it was not clear whether the copy held in the human resources department in Essex was an original or might also be a copy. This was particularly the case with regard to translations of overseas references which were not addressed to Caring Homes Ltd. All files had a recent colour photograph of the staff member. Where required staff had up to date Home Office registration. Health information is provided by the applicant. Exemption to the European Working Time Directive were signed as appropriate. Staff are provided with a contract. All new staff are provided with a copy of the General Social Care Council (GSCC) Code of Conduct on appointment. All staff receive induction training. This consists of one days orientation to the organisation and the home, one days video based training on mandatory subjects and further training on a wide range of matters which is completed by the new member of staff and their supervisor - usually within three months of appointment. Training events together with required or planned attendance are summarised on a spreadsheet. In addition there is a training plan for the current year (April 2006 to March 2007) The organisation intends to support staff onAge Care Awards (a Sussex based training agency specialising in care of older people) at NVQ levels 2 & 3 and BTEC certificate in the care and support of older people. It is expected that this will support conformance to the National Occupational Standards for the sector. DS0000019195.V287778.R02.S.doc Version 5.1 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): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home does not have a registered manager. However, systems are in place to ensure that the home is run in the best interests of residents. However, health and safety at the home need to be conscientiously managed to ensure that residents and staff safety and welfare are not compromised. EVIDENCE: The home had a temporary manager at the time of this inspection. The postholder is an experienced registered nurse and was previously a registered manager. The area manager confirmed that an appointment had been made to the permanent post. This information was circulated to staff, residents and relatives towards the end of the day of inspection. The temporary manager had worked in the home for just over six months. She said that she endeavoured to maintain an appropriate ethos in the home by having an open door policy for residents, staff and relatives, by being out and about on the floor, and DS0000019195.V287778.R02.S.doc Version 5.1 Page 22 demonstrating partnership working with a wide range of external professionals including tissue viability nurses, dieticians, physiotherapists and social workers. Some relatives’ comments were positive about the manager and area manager’s leadership style. The organisation has a systematic approach to quality assurance. The home is responsive to CSCI requirements and recommendations. A stakeholder’s survey was conducted in July 2005 and is expected to be repeated this year. The manager had recently introduced a care plan audit, the results of which had been discussed with staff. Policies and procedures are in the process of being reviewed. The results of an annual service user and staff feedback survey was provided for the inspection. It showed a good to high level of satisfaction with the items measured and an overall improvement with the results of the same exercise conducted in May 2005. A system of staff supervision is in place. The process is structured by the use of a checklist which addresses 14 subject areas and has space for notes at the end. Records were made available for inspection and were found to appropriately address practice issues. The home has procedures for managing small amounts of money on behalf of residents. The money held in the home is not pooled. Each resident has a transaction sheet and written records are maintained of all incoming and outgoing payments. The home’s training matrix highlighted that staff had undertaken training updates in moving and handling and fire awareness. The names of designated first aiders were displayed in the home. The fire panel is checked weekly and a record is maintained. It was evident that all zone areas in the building are regularly activated. Food stored in the refrigerator was appropriately dated and labelled. The food storage cupboard was tidy. It was noted that staff was using the storage cupboard to store their personal clothes such as coats. This is not a good practice. It is recommended that this practice should cease. COSHH sheets were in place for all cleaning materials and substances that were being used in the home. Domestic staff spoken to confirmed that the domestic supervisor had cascaded training in the use of COSHH solutions. They felt that the induction training they had undertaken was adequate and enabled them to perform their duties to a high standard. Monthly checks on hot water temperatures in wash hand basins in residents’ bedrooms, bathrooms and toilets are carried out. Temperatures were within the appropriate range. However, hot water temperatures in staff areas such DS0000019195.V287778.R02.S.doc Version 5.1 Page 23 as toilets exceeded the normal range. It is required that hazard-warning signs be displayed over taps. Generic risk assessments were in place for safe working practices and were regularly reviewed. It was noted that two gas cooker rings in the general kitchen were defective and needed to be replaced. The extractor fan was also faulty and must be repaired or replaced. The paintwork in the ceiling was flaking and required to be stripped and repainted. The portable appliance testing (PAT) record was checked and it was evident that all electrical equipment in the building was being maintained. DS0000019195.V287778.R02.S.doc Version 5.1 Page 24 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 DS0000019195.V287778.R02.S.doc Version 5.1 Page 25 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 OP9 Regulation 13(2) Requirement The manager must ensure that trained nurses administer and record medication in accordance with the nursing and midwifery guidelines. (Previous time scale of 30/11/2005 not met). The manager must ensure that a lockable storage facility is provided in the resident’s bedroom who self-medicates to store prescribed medication. The manager must ensure that maintenance issues identified in standard 19 of this report are carried out. The manager must ensure that weaknesses identified in the home’s recruitment procedure are remedied. The manager must ensure that hazard-warning signs are displayed on hot water taps in staff toilets. The manager must ensure that the two defective gas rings on the gas cooker in the general kitchen and the defective extractor fan are replaced. DS0000019195.V287778.R02.S.doc Timescale for action 04/05/06 2 OP9 13(2) 04/05/06 3 OP19 23(2)(b) 30/06/06 4 OP29 19(1)(c) 31/05/06 5 OP38 13(4)(a) 30/06/06 6 OP38 OP38 30/06/06 Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP26 OP29 OP38 Good Practice Recommendations It is recommended that the manager should ensure that the daily progress report include references to identified needs recorded in individuals’ care plans It is recommended that the manager should clarify with nursing and domestic staff who is responsible for the cleanliness of the sluice room floors. It is recommended that the manager and responsible individual should ensure that the home’s application form be reviewed. It is recommended that the manager should ensure that the practice of storing staff’s coats in the food storage area in the general kitchen be ceased. DS0000019195.V287778.R02.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000019195.V287778.R02.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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