Inspection on 23/05/07 for Derby House Nursing Home

This inspection was carried out on 23rd May 2007.

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

The inspector 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

Derby House Nursing Home 27/06/06

Derby House Nursing Home 01/11/05

Derby House Nursing Home 04/07/05

Derby House Nursing Home 28/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Derby House Nursing Home 12 Broad Walk Buxton Derbyshire SK17 6JS Lead Inspector Sue Richards Key Unannounced Inspection 23rd May 2007 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 Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derby House Nursing Home Address 12 Broad Walk Buxton Derbyshire SK17 6JS 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) 01298 23414 01298 23334 Derby House Nursing Home Limited Mr Derek Andre Brindley Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability (1) of places Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Derby House Nursing Home is registered to provide personal care with nursing to male and female service users who fall within the following categories: Old age, not falling within any other category (OP) 31. Physical disability (PD) 1. No persons can be accommodated under the category PD at Derby House nursing home when one person is already accommodated under this category. Derby House Nursing Home can accommodate the two named variations for the category of PD approved on the 1/4/2002 and 6/10/2005. The maximum number of persons to be accommodated at Derby House Nursing Home is 31. 27th June 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Derby House is located in the heart of Buxton, overlooking a park within a pleasant residential area. The home is an old Victorian building, initially registered under the Registered Homes Act 1984, transferring under the Care Standards Act in 2002. Accommodation is over three floors and is suitably adapted to meet the needs of residents with mobility problems, with a range of mobility aids provided. There is a shaft lift and emergency call system provided throughout. There is one communal lounge/dining room available on the first floor, although floor space and facilities here are limited in terms of the number of residents that use this room at any one time. However, due to the size of many individual bedrooms, most residents prefer to use these as bed sits. There is a choice of bathrooms and toilet facilities and a central kitchen and laundry. Staff facilities are also provided. Residents receive care and support from a team of registered nurses, care and hotel services staff, together with the registered manager, who is also a registered nurse in both mental and general nursing. Ownership of the home is a family concern and the registered providers are on site daily. Fees charged range from £486.00 to £611.00 per week. This information is correct as of 09 April 2007 and as detailed within the pre-inspection questionnaire returned by the provider. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For the purposes of this inspection we have taken into account any relevant information the Commission holds about the service, the previous key inspection report from May 2006 and the requirements of that report, a preinspection questionnaire completed by the registered persons for the purposes of this inspection, 19 completed service user survey returns and our findings from our visit to the home on 23 May 2007. During our site visit to the home, case tracking was used as part of our methodology. This included three service users whose care and service provision was more closely examined. Discussions were held with them and with staff about their care, their private and communal accommodation inspected and their care and associated records were examined. What the service does well: What has improved since the last inspection? Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 6 The requirements made at that inspection are complied resulting in service users medicines records being appropriately maintained and the effective promotion of identified safe working practises of staff. Records kept in respect of activities organised in the home and individual’s participation in them is developed considerably. Comprehensive induction records are kept for all staff in accordance with Skills for Care standards. What they could do better: Ensure the home’s statement of purpose/guide includes full details as to the range of needs the home is registered to provide for and promote the availability of the guide in alternative formats. Provide a record for each service user as to their personal choice and ability with regard to retaining and managing their own medicines in order to promote individuals’ autonomy and independence as far as is reasonably possible. Promote written agreement with service users about their care plan wherever possible to reinforce their rights of consultation and choice. Ensure that personal information about service users is always kept confidential in order to promote their privacy and dignity. Regularly review/consult with individual’s (or their representative where this is not possible) about their daily living routines and arrangements to ensure that their lifestyle experienced in the home continues to match with their expectations and maintain a record of those consultations. Ensure that staff is ready to assist service users with eating and drinking without continuous interruption in order to promote their best interests and individual dignity. Routinely provide lockable storage space in all bedrooms thereby promoting individual choice. The same applies to the provision of suitable locks to bedroom doors. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS1, 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are usually provided with sufficient information about the home and there is a consistent and structured approach to the assessment of individual’s needs. EVIDENCE: Details of service users accommodated were provided within the pre-inspection questionnaire and the home’s statement of purpose was examined in conjunction with this and the home’s certificate of registration. The statement of purpose/service guide did not include information regarding the accommodation of service users who may have physical disabilities as detailed on their certificate of registration. This was discussed with the registered persons who agreed to amend this. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 10 The service guide is readily available in a loose-leaf standardised type format. However, the registered persons advised that it could be made available in other formats if necessary, such as large print, although this was not actively promoted/advertised. Key comments and views made about the service by existing service users and their representatives are provided with the guide, which are regularly updated. Of a total of nineteen survey questionnaire returns completed by service users or their representatives, eighteen said that they had received a contract regarding their care and accommodation in the home and one was awaited. Seventeen said that they had received enough information about the home before moving in so they could decide if it was the right place for them, although two felt they had not been given enough information, although did not specify further. Comments received, included: ‘We were impressed by the thoroughness and time spent going through all aspects of the home and the time and care spent on advice as to what may be best for mum.” “All information given was well presented and time was given to talk things through with a visit and full tour of the home.” Of those service users case tracked during the site visit, two said they were provided with information about the home and its services, although one of those felt that the range of needs the home provides for by way of those service users currently accommodated, was not made completely clear. The recorded needs assessment information for those service users case tracked was examined, including pre-admission assessment information. This was well recorded and records of reviews, which included the service user as able, and their representatives, were also kept. However, needs assessment information did not details individual’s personal choices and abilities with regard to retaining and managing their own medicines. Needs assessment information recorded was comprehensive and detailed the majority of service users individual daily living routines and lifestyle preferences. (See also section 3 of this report). The home does not provide for intermediate care. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 11 Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are suitably recorded and their health care needs are well accounted for and are met. EVIDENCE: The written care plans of those service users case tracked were examined. Discussions were also held with service users about their care and with staff regarding the arrangements for the organisation and delivery of care. Care plans detailed care interventions in accordance with individual’s risk assessed needs and had regularly recorded reviews. They were also reflective of recognised guidance concerned with the care of older persons, including that relating to clinical practise. Service user who were able, were not directly involved in the drawing up of their care plans and these were not signed as Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 13 agreed by them. However, records of their care reviews detailed their involvement in these. Two of the service users case tracked expressed satisfaction with their care and said that their health care needs were well met in accordance with their preferences and that staff always treated them with respect and promoted their dignity and privacy. The Inspector was not able to engage in meaningful discussion with the third service user due to their mental capacity. During the site visit we observed that individual’s bathing routines were openly displayed on a white board in bathrooms for the purposes of staff information, which does not best promote their privacy and dignity. This was discussed with the registered persons who agreed to ensure more suitable arrangements. Inputs from outside health and social care professionals were well accounted for, including specialist and routine health care screening and service users are encouraged to be independent and visit local outside healthcare professionals wherever possible. Out of a total of nineteen survey questionnaires returned completed by service users or their representatives, thirteen said that they always received the care and support they needed and six said they usually did. Comments received included “ “ “ “ Everything I have asked they have taken notice.” Excellent care with very caring staff.” I am very well looked after and get on very well with staff.” Staff are always on hand for advice and will keep us up to date with regards mum’s heath and wellbeing, as well as being kind and friendly.” Fourteen survey returns said that they always received the medical support they needed and five said they usually did. Sixteen survey returns said that staff listened and acted on what service users said (or their representatives as appropriate). One said they sometimes did, and one person said that they usually did, although this person felt that individual autonomy could be better promoted. The arrangements for the management and administration of service users medicines were examined and discussions held with the service users case tracked. The Inspector was advised that there were no service users who had chosen to manage their own medicines at the time of the site visit, although lockable storage was not routinely provided in service users own rooms to enable safe storage of medicines should any prospective service user choose to do so. (See also the Environment section of this report). Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 14 Needs assessment information did not details individual’s personal choices and abilities with regard to retaining and managing their own medicines. (See the Choice of Home section of this report). In all other respects medicines arrangements were totally satisfactory. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Daily living routines have some flexibility, activities are routinely organised and meals are balanced and nutritious, although each of these may not always be in accordance with individual’s lifestyle preferences. EVIDENCE: Discussions were held with service users case tracked as able regarding the arrangements for their social, religious and recreational interests and needs and discussions were also held with a staff member responsible for their organisation. Activities sessions are held in the home on Tuesday and Thursday afternoons on the basis of group and social interaction. Service users case tracked said that they were selective in their attendance at these. One of the service users regularly attended and was an active member in a church of their choice and also continued to manage their own financial affairs. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 16 All said they were encouraged to bring their own personal possessions into the home on their admission. There were no service users accommodated with diverse cultural needs, although some had differing religious needs, which were accounted for. Information is provided in the home’s statement of purpose regarding its philosophy, core values and how it aims to promote these on an individual basis. Overall feedback from service users both verbally and via survey returns indicated they felt that their daily living routines were reasonably flexible. Although some felt that they were not always in accordance with their lifestyle preferences. Comprehensive records were very well kept regarding activities. These included some information regarding individual’s known lifestyle preferences and hobbies and also their participation and engagement in those group activities. Activities sessions were also used to consult with service users about arrangements and choice of activities and minutes were kept of those consultations. Minutes seen also included recent discussions with service users regarding the redecoration of the lounge and choice of fabrics and colours schemes. One of the service users case tracked is involved in producing information about activities for other service users on their computer, including large print and simple picture formats and also daily menus. Examples of activities organised in the home include, general knowledge and quizzes, chair aerobics, nostalgia/reminiscence, bingo, history group, arts and crafts, music and movement and board games. Seasonal celebrations are also held. Two of the service users case tracked said they regularly went out into the local community either independently or with personal support as necessary and could have visitors whenever they chose. Visiting to the home is open. There were plans in hand for trips out to Chatsworth and a seaside visit, local well dressings and the town carnival. Of the nineteen survey returns, three said that activities were always arranged by the home, which they could take part in. Eight said they usually were, seven said sometimes and one said never. Three clarified that the activities provided did not suit their choices or lifestyle preferences. Four surveyed said they always liked the meals at the home, ten said they usually did and four said they sometimes did (one did not answer this question). One said they were often given too much. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 17 Lunches were observed being served. These were suitably presented in varying portions in accordance with the assessed needs and preferences of those service users. Many took their lunch in their own rooms. Three service users took lunch in the lounge/dining room and staff assistance was provided to assist two of those with eating and drinking. However, the staff member doing this left on a number of occasions during each of their meals to attend to other service users who required assistance in their own rooms. Two survey returns gave the stated opinion that more staff time is needed for people who require feeding in order not to rush them. This issue was also raised in the last key inspection report for this service. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know how to complain. Complaints made are taken seriously and service users are protected from abuse. EVIDENCE: There is a complaints procedure in place for the home, which is openly displayed in standard print format and information regarding how to complain is also provided within the statement of purpose/home guide. The registered persons advised that both are in the process of being reviewed and updated with regards to accurately reflecting the Commission’s role and the complainants’ rights to contact CSCI at any time they so choose. They also advised that large print format can be provided at any time as required by any service user. Service users spoken with said they knew how to complain and out of those who completed survey returns, fourteen said they knew as to who they would speak to in the home if they were unhappy and five said they usually did. All said they knew how to complain and all except one said they were confident to do so. Many were confident in that their concerns were usually listened to and that matters were dealt with without the need to complain. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 19 The home provided records of complaints received since the previous inspection of this service. Two complaints were recorded, including action taken and outcomes. Both of the complaints were made by a relative of two different service users and alleged their unkempt appearance. Records indicate that both were partially substantiated and resolved to the satisfaction of the complainants. With the exception of one very new staff starter, who was working under supervision, all staff spoken with was conversant with the home’s procedures and appropriate action to take in the event of any suspicion of or witnessing the abuse of any service user and also with regard to complaints. Staff is routinely provided with training regarding recognising abuse and protection of service users. There have been no reported incidents during the last 12 months requiring referral under joint agency safeguarding adults’ procedures. However, one incident occurring 14 months previously was reported by the home and well managed by them in accordance with recognised procedures and their responsibilities. The home provides policy guidance for staff in respect of its practises regarding service users’ money and financial affairs and dealing with aggression. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19, 24 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, safe and comfortable environment, which for the most part suits their needs. EVIDENCE: The private and communal accommodation of service users case tracked was inspected. All areas seen were clean, safe and well maintained. Service users who were able to express a view said that they were satisfied with their own rooms, which were personalised and they felt that for the most part they suited their needs. Two of the service users said that they would like to be able to lock their own rooms and were of the understanding that arrangements Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 21 were being made for suitable lock to be fitted to their doors. The registered persons confirmed this was so. Lockable storage space is not routinely provided in bedrooms, although one of the service users case tracked felt they would like to have this facility. Given that there is only one average sized lounge, dining area, service users tend to spend a large amount of time in their own rooms, which are large bed sit type rooms. Service users spoken with said that they were aware of this before moving into the home. At the last key inspection of this service requirements were made regarding safe working practises in the home. These were complied with at this inspection. During discussions with staff about the home, some felt that bathrooms required review with regard to moving and handling needs of some service users. This was discussed with the registered provider who advised that the viability of this was being assessed. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are generally well met by staff that are suitably recruited, inducted and trained and they are well protected by the home’s recruitment policy and practises. However, staff availability at lunchtime may not always best promote service users best interests or their personal dignity. EVIDENCE: The arrangements for the recruitment, induction, training and supervision of staff were discussed with management and individual staff members and associated records were examined. These were satisfactory. Seventy five percent of care staff have achieved at least NVQ level 2 or above and there is clear planning for new staff starters to aim to achieve these. Discussions were also held with service users regarding staff availability and feedback regarding the same is also accounted for from the nineteen surveys returned. Service users spoken with during the inspection visit said that staff was usually available. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 23 Of the nineteen survey returns, six said that staff is always available when they need them, eleven said they usually are and two said they sometimes are. A few comments received suggested that there should be more staff around to assist service users with eating and drinking at lunchtime (see also Daily Life and Social Activities section of this report) in order to make this less hurried for individual’s who may require assistance. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31, 33, 35, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run and the health, safety and welfare of service users and staff is promoted and protected. EVIDENCE: The registered manager is a registered general and mental nurse and is also one of the registered providers, who are a very much a hands on and committed family concern. A strong awareness of current developments, both nationally and by the Commission was demonstrated during discussions with Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 25 them together with a consistent approach to ensuring staff adherence to policies and procedures during their practise. There is a formal quality assurance system in operation, which includes an annual audit of all national minimum standards for the care of older persons. Satisfaction questionnaire surveys are also sent out to service users, their representatives and other stakeholders on a periodic basis. Details of the most recent audits were provided, including quality assurance and business planning for 2007-08. Discussions were held with service users as able regarding consultation with them and the arrangements for the management and handling of residents monies (those case tracked) were also examined and are were satisfactory. The arrangements for staff supervision were discussed with staff and also the registered persons and records were examined in respect of these for the four most recent staff starters. These were satisfactory. A number of records, which are required to be kept in the home, were examined. These are referred to under the relevant sections of this report and included, care records, complaints records, staff records (recruitment, training and supervision) and accident records. They are appropriate maintained and safely stored. Details of the arrangements for staff training in respect of safe working practises were discussed with the registered provider and staff. These were in accordance with the information provided on the pre-inspection questionnaire and individual staff training records and were satisfactory. Details of the arrangements for the annual maintenance of equipment in the home were provided by way of the pre-inspection questionnaire. These were satisfactory. The arrangements for the recording and reporting of accidents and untoward incidents in the home were discussed with staff and records examined. These were satisfactory. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 26 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 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 3 17 X 18 3 3 X X X X 2 X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The home’s statement of purpose must include full details as to the range of needs the home is registered to provide for. (In this instance referring to physical disabilities as per the home’s certificate of registration). Timescale for action 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP3 Good Practice Recommendations The availability of the service guide in alternative formats should be more actively promoted. Recorded needs assessment information for each service user should include details of their personal choices and abilities with regard to retaining and managing their own medicines. Care plans should be agreed and signed by the service user whenever capable. Details of services users bathing routines should be removed from open display in bathrooms in order to DS0000002052.V337226.R01.S.doc Version 5.2 Page 28 3. 4. OP7 OP10 Derby House Nursing Home 5. OP12 6. 7. OP15 OP24 8. OP27 9. OP31 promote their dignity and privacy. Bathing routines should be determined and agreed with each service user and their preferences recorded in their individual care files. NMS 14 also applies here. Regular consultations should be established with each service user (or their family representative where this is not possible) on an individual basis with regard to their daily living arrangements, activities and choice of food to ensure that their lifestyle experienced in the home matches with their expectations and a record of those consultations should be kept. Staff should be ready to assist service users with eating and drinking where necessary, such that time is spent to ensure they are given sufficient time. All residents should be routinely provide with suitable locks to their bedrooms doors, (which may be easily accessed by staff in the event of any emergency) and also lockable storage space, thereby promoting residents own choice as to whether or not to used them. A review of staff availability at around the lunchtime period should be undertaken to ensure that staff are ready and provide consistent time to assist service users with eating and drinking as necessary. The registered manager should seek to achieve an NVQ level 4 in management or equivalent. Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Derby House Nursing Home DS0000002052.V337226.R01.S.doc Version 5.2 Page 30 - 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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