Inspection on 12/02/07 for Eastbury Nursing Home

This inspection was carried out on 12th February 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Eastbury Nursing Home 09/02/06

Eastbury Nursing Home 06/06/05

Eastbury Nursing Home 18/10/04

Eastbury Nursing Home 24/06/04

Eastbury Nursing Home 14/10/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Eastbury Nursing Home 12 Eastbury Road Northwood Middlesex HA6 3AL Lead Inspector Sarah Middleton Key Unannounced Inspection 12th February 2007 09:55 Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 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 Eastbury Nursing Home DS0000010930.V324906.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 Adults 18-65. 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. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastbury Nursing Home Address 12 Eastbury Road Northwood Middlesex HA6 3AL 01923 823 816 01923 841 623 info@mdhomes.co.uk 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) MD Homes Mrs Subiha Tabassum Hussein Care Home 20 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0), of places Physical disability (0) Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Adults over 40 in need of general nursing Physical Disability Learning Disability Mental Health problems Minimum Staffing Notice Date of last inspection 9th February 2006 Brief Description of the Service: Eastbury Nursing Home is a converted detached house situated in a residential area. It offers support and care twenty-four hours a day to a varied group of service users. The needs cared for are service users who have Physical Disabilities, Learning Disabilities, Dementia or Mental Health Needs. The home has a large well maintained private garden to the rear and car parking facilities at the front. Local transport facilities are available in the form of buses and Northwood underground station, which is within walking distance of the home. The accommodation consists of ten single and five double bedrooms. The first floor of the home has four single and two double bedrooms. There is a Parker bath, with shower attachment and two toilets on this floor. Two new walk-in shower rooms are available, one on the ground floor and one on the first floor. There is a stair lift for those service users unable to manage stairs. The home has a spacious conservatory, which is light and bright. Smoking is allowed at the home in one designated area, either in a part of the lounge or in the garden. The Registered Providers are MD Homes. There is a Registered Manager and a Group Operations Manager, who deals with the financial and personnel management of the four homes within MD Homes. The fees range from £1,020-£1,800 per service user, per week, depending on the needs of the individual service user. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out as part of the regulatory process. The inspection was from 9.55am- 4.55pm. There were no service user vacancies and no staff vacancies at the time of the inspection. The Inspector carried out a tour of the home, viewed a sample of service users files and maintenance records. Three members of staff and five service users were spoken with as part of the inspection process. Four family members had completed comment cards and thirteen service users had completed surveys and these had been returned to the CSCI. Overall feedback was positive and any relevant comments from the surveys or discussions with service users or visitors have been included into this report. The Registered Manager assisted with the inspection process and the Inspector would like to thank all those who contributed to this inspection. All of the Key Standards were inspected at this inspection. The two requirements made at the last inspection were met and three new requirements were made at this inspection. What the service does well: What has improved since the last inspection? The home now ensures they have photographs of each service user. When medication had been administered the medication administration records had been signed. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are assessed prior to admission into the home. EVIDENCE: The Registered Manager described the pre-admission process to the Inspector. A referral is taken and an enquiry form is completed with the basic information regarding the prospective service user. The Group Manager then arranges to meet with the prospective service user and usually either the Registered Manager or Deputy Manager also attends this initial visit. A pre-admission assessment is completed and this gives the home the information they need to decide if they can offer a place. The Inspector viewed a completed preadmission assessment. This covered a range of areas such as medical history, relationships, mental health, personal care needs and spiritual needs. It was noted that this particular service user wanted to take on a new faith and religion and this was acknowledged and supported by the home. The prospective service user and/or their representatives are then encouraged to visit the home in order to meet with other service users and members of staff. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 9 The home then completes an assessment form as soon as the service user moves into the home. This information, along with the pre-admission assessment assists with the development of the initial care plan and risk assessment. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service user care plans show their individual needs and how these are to be met. Service users are encouraged to make decisions about their daily lives. Risk assessments are completed and aim to safeguard service users, whilst supporting them to be as independent as possible. EVIDENCE: The Inspector viewed a sample of care plans. Care plans are completed by Management with additional input from, keyworkers, service users and/or their representatives. The care plans viewed had the service users photograph and were individual, detailed and covered a wide range of needs, such as, mobility, smoking, personal hygiene, family and physical health. Each part of the care plan described the need and how this need was to be met by the staff team. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 11 One care plan viewed had a service users writing on some of the areas identified as their needs. This particular service user had made comments regarding the needs identified. Clearly, where able, service users are included in the development of their care plan and where able, service users can disagree with the needs that have been identified by staff. Another care plan viewed was regarding a service user who is completely dependant on staff and is bed bound. Recorded on the care plan was the care and support this service user would need to maintain good health and a positive quality of life. Care plans are reviewed either monthly or three monthly, depending on the age of the service user. Care plans are also updated and amended when there has been a change in service users needs. A main annual review takes place, usually organised by Social Services and where appropriate, regular Care Programme Approach reviews are held to monitor a service users mental health needs. Daily records were also seen and these outlined the personal care support given, the mood of the service user and any other relevant information that needed to be shared amongst the staff team. Service users abilities and preferences are known and supported by the staff team. Staff respect the individual rights of each service user and aim to promote service users to be able to feel they have a choice in their everyday life. One comment from a service user’s survey stated that they have the freedom to do what they want. Two service users have an advocate from the local mental health charity called Rethink. This organisation is due to close, although the two advocates will remain working and supporting the two service users. The Registered Manager is concerned that there will be no other advocates available from other organisations, to support those service users who might require this independent help. Where able, service users manage their own personal finances. Risk assessments were viewed and these are reviewed and altered whenever there is a change in need. The risk assessments were detailed covering subjects such as, risk of falling, mental health, nutritional risks and risk of developing pressure sores. A more general risk assessment was also completed. The home talks with service users who wish to go out independently to ensure the home and service user is confident they will manage going out into the community unescorted. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities are available for service users both in the home and out in the community. Service users are able to maintain social relationships with family and friends. The rights of service users are promoted and respected. The dietary needs of service users are catered for and meal provision aims to provide a nutritious and varied diet. EVIDENCE: Social activities are in place for those willing and able to take part in them. Some service users attend a local day centre, whilst others prefer to relax in the home. The home shares an activities co-ordinator with the other local registered care homes owned by the same Registered Provider. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 13 The Inspector viewed a report completed by the activities co-ordinator, where they outlined the work they had been doing in getting to know the service users and discovering their individual interests. A newsletter is also produced informing service users of forthcoming events. The activities co-ordinator has set up a day centre that operates at one of the local residential care homes. The service users living at Eastbury can access this day centre. Pub meals and a trip out to see the Christmas lights had been recent events, along with organising holidays for those service users interested. In addition, the home has daily planned activities, such as bingo, scrabble and arts and crafts. There are ongoing difficulties in motivating some of the service users to engage in meaningful activities. Those service users asked stated they were able to keep as busy as they felt able to. The Inspector saw some service users reading magazines, newspapers and playing scrabble with other service users and staff. There is also a computer, where games such as solitaire are played. One service user was seen to be playing this game on the day of the inspection. One service user informed the Inspector that they attend the local church and church people also visit the home. Another service user has a pray mat and the Quran in order for them to follow their cultural and religious needs. Once a fortnight an aromatherapist visits to offer massages to those interested in receiving this service. The home documents on a daily basis the activities service users have engaged in during each day. This enables the home to monitor who is taking part in the different options available to them. For many service users, listening to music and talking with other service users or staff is all that they feel able to do. Each service user’s abilities and interests are recognised by the staff team. Family and friends can visit the service users throughout the day. They can meet in private or in the communal areas. Some service users, who are able to, go out without a member of staff to visit their family or friends. Service users have access to most areas of the home and can freely talk with Management, as the office door is open. There are locks on bedroom doors and the Registered Manager stated that three service users currently lock their bedroom doors. Service users receive their personal mail, although they often then pass this on to Management so that appointments and important information is known to staff. Staff were seen to interact with service users throughout the inspection. Service users confirmed that they were able to spend time alone, or in the company of others. The Inspector met with the cook, who works six days a week in the home. Discussions took place with the cook regarding the recent training they had attended. This was a six-month course on infection control and health and safety. The cook was able to give examples of what they had learnt from this training, such as appropriate food temperatures and storage. They commented positively on the course as it had given them new information to consider when handling and cooking meals. They are also hoping to study for an NVQ in the near future. The cook is included in the general training provided in the home. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 14 Menus are on a four-week rolling programme and are devised by the cook, Registered Manager and service users. The Inspector viewed the menus and these showed a wide range of meals provided for the service users. Service users can also request alternative meals and these are recorded by the cook. The Inspector sampled the lunch being offered on the day of the inspection and found this to be well presented and tasty. Service users commented positively on the meal provision in the home, stating it was varied and there was plenty of it. Rice was being offered for those service users who preferred this type of food. Cultural needs are also considered and halal meat is used in meals. The cook was aware of the individual service users dietary needs. The Inspector spoke with the cook about having a permanent list of all the individual dietary requirements so that should there be a replacement cook working in the kitchen then they would easily be able to refer to this information. This was made a recommendation to action as soon as possible. The kitchen was clean and tidy on the day of the inspection and is due to be updated in the future, however a date has not been confirmed for when this work will commence. Fridge and freezer temperatures had been taken and were within an appropriate range. Food that had been opened or prepared was wrapped and dated with the date and time of the preparation. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users receive personal care support in the way that they prefer and in private. Service users health needs are recorded and are being met. The home has robust medication systems in place to safeguard service users. EVIDENCE: Personal care is offered in private and where service users share a bedroom, screens are provided. The level of support each service user needs varies, as some require full support, whilst others need prompting to bathe, or change their clothes. Those service users asked, confirmed they could go to bed and get up whenever they choose to. Service users can choose gender specific care, although the Registered Manager stated no service users had asked for this so far. Service users are assigned keyworkers so that their individual care and needs can be monitored. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 16 Service users health needs are clearly recorded on care plans. Various health professionals visit the home such as GP, Community Psychiatric Nurses and Opticians. Currently there are no service users with pressure sores. When this has occurred the home can seek additional advice from the Tissue Viability Nurse, who mainly offers support via the telephone. When service users have seen a health professional, this is recorded onto a medical appointment form so that staff can easily monitor when service users have received treatment. The Registered Manager had devised a checklist to ensure, when they are due, routine blood tests are carried out. As noted earlier, there are two service users who remain in bed all of the time. Their care is carefully monitored, with charts showing when they have been turned; this is done in order to prevent pressure sores developing. The recording of fluid intake is also carried out. These particular service users have detailed risk assessments regarding their specific needs, as they are vulnerable to infection and other health problems. Service users weight, where possible, is taken on a regular basis, in order to monitor any significant changes. Medication systems were inspected and the Inspector viewed a sample of medication administration records. These had been completed correctly. Only qualified nurses administer medication. The Deputy Manager stated they had recently attended an information and training day held by the CSCI on the subject of medication, which had proved to be useful. The Registered Manager also stated that she would be contacting the local Pharmacist to provide refresher training for the staff team. A sample of loose medication was counted and this was correct. The home had one type of controlled drug in the home, Temazepam 10mg. This was stored in a separate metal locked cabinet. The Inspector viewed the controlled drugs register and this had been signed and counted on a daily basis by two members of staff. The amount recorded was the correct amount in the home. Regular spot checks are carried out on all of the medication and this is signed once Management have checked it. Creams and liquids opened had dates of opening written on them to ensure out of date stock is not used. The fridge where medication is stored have the temperatures taken on a daily basis and those viewed were within an appropriate range. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel they can talk to Management if they have a comment or complaint and that they would be listened to. Systems are in place to protect service users from abuse. EVIDENCE: The home has received no complaints in the past two years. The Inspector viewed the complaints records. This book records the complaint and any action taken with regards to the complaint. The complaints procedure is freely available and is located in the communal hall of the home. Those service users asked said they would feel able to talk to Management about any concerns they might have. The completed service user surveys also said they would be happy to go to Management if they wanted to raise a comment or concern. The Registered Manager also felt that the majority of service users would come to her to talk through any issues. Where service users could not verbally make a complaint, then usually a family member would on their behalf. The home has not had any protection of vulnerable adults, (POVA) investigations or allegations. Staff receive training on the protection of vulnerable adults and the Registered Manager stated that she saw this subject as mandatory for all staff to receive information and training on. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 18 The home has copy of the Local Authority’s safeguarding adults policies and procedures. Those staff asked stated they would report any POVA concerns to Management. The Inspector discussed service users finances. The home holds some service users personal finances and keeps this money locked up, where only the Registered Manager and Deputy Manager have access. Each financial transaction is recorded into a book and the Registered Manager stated that the head office audit these books and receipts. The Inspector counted a small sample of service users finances and found these all to be correct. Some service users handle their own monies, whilst others finances are managed by either family members or the Local Authority. Service users pay for certain services, such as haircuts, holidays and trips. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers service users a warm and comfortable environment to live in. Service users bedrooms offer them the option to be alone and have privacy when they want this. The home was clean and free from odours at the time of the inspection. EVIDENCE: The Inspector carried out a tour of the home and samples of rooms were viewed. The home has a maintenance refurbishment programme where areas are identified that will need improving or updating. The Registered Manager makes requests for improvements to the home at the Managers meeting. The home had two new walk-in shower rooms installed, one on the ground floor and one on the first floor. The Registered Manager said that she would like to start updating some of the chairs and furniture in service users bedrooms. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 20 Overall the home is bright, clean and modern, with a spacious conservatory and garden for service users to have time alone or to see family or friends. The home has a maintenance person who visits the home once a week to carry out minor jobs that need attention. Jobs are written in the maintenance book and these are checked and ticked off when the work is completed. The Inspector met with one service user in their bedroom. This had been a double room but was now single and was a large spacious bedroom. The service user said they were happy with their bedroom and that they could have personal possessions with them in this room. There was plenty of space for the service users books and clothes. The Inspector viewed the laundry room. Staff wash the service users laundry and soiled items are washed in red bags that dissolve in the wash. Washing machines have a sluice cycle for items requiring this. The home has one domestic member of staff who carries out the majority of domestic tasks. The home was free from offensive odours at the time of the inspection and those rooms viewed were tidy and welcoming. Staff receive training on infection control and health and safety issues. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and qualified staff team, who are aware of their roles and responsibilities, support service users. Health declarations need to be signed and available for inspection to ensure staff are fit to support and care for the service users. The contents of inductions need to be evidenced and available for inspection to ensure new staff receive a detailed induction and can appropriately support the service users. Training attended also needs to be recorded in order to demonstrate that staff are up to date with the skills and knowledge they need to fully care for the service users in a safe way. EVIDENCE: The home has nurses and care workers working in the home. The unqualified care workers are supported to study for an NVQ and the home is meeting its target for a minimum of 50 of care staff obtaining this qualification. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 22 Many of the staff have worked in the home for several years and know the service users and their individual needs. The Inspector noted that staff spoke with service users in a courteous and professional manner. Service users commented positively on the staff and said they were caring and available to talk to. Training subjects aim to cover the different needs service users have, such as diabetes and mental health. Staff asked stated that the team works well together and for one member of staff who had just started working in the home they felt that staff had been helpful and supportive. There is always a qualified nurse working on a shift and sufficient numbers of care staff were seen to be supporting service users. Generally there is a low turnover of staff and the home does not use agency members of staff. The staff team reflects a mixture of ages, gender and cultural backgrounds and to some degree this reflects the diversity of the service users. Staff confirmed that team meetings are held and the Registered Manager stated these were held every two to three months. Samples of staff employment files were viewed and these had completed application forms, Criminal Record Bureau Checks, two references and a recent photograph. One staff file seen did not have a signed health declaration and a requirement was made for this shortfall to be addressed. The home uses the Skills For Care Induction book to work through, which covers a range of subjects that new members of staff work through. Management then signs off this book. For one of the newest members of staff to join the team, their induction book was not available and therefore there was no written evidence to suggest they had gone through a structured detailed induction, although those members of staff asked did confirm that they had received an induction from Management. The need to evidence the type of induction provided in the home is important, as new staff need sufficient training and information before working and supporting the service users. A requirement was made for written induction programmes to be available for inspection. The Inspector viewed the training staff had attended. The Registered Manager keeps a record of individual members of staff training, however some of the training records were not up to date and the information available indicated that there were some members of staff that were out of date with the mandatory training. A requirement was made for the training records to be kept up to date, so that it is easy to identify what courses are needed to be booked for each member of staff. The Mental Capacity Act 2005 that is to become legislation in April is familiar to the Registered Manager, as she had attended training on this subject. She has booked several members of staff to attend this training so that the home is ready to implement this legislation into their daily work. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 23 Overall training is accessed through the Local Authorities and the Registered Manager stated that this has been a successful way of accessing training. The Inspector discussed with the Registered Manager the need to consider exploring other options, as sometimes courses might not be available when they are needed. The home must always ensure that they do not have a staff team that are waiting for weeks or months for courses to be advertised. If this becomes an issue in the future, then the Registered Manager should consider alternatives. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home. Service users can be confident that their views contribute to the ongoing reviews and improvements to the home. The health and safety of service users is promoted and protected by the appropriate checks and maintenance of the home. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 25 EVIDENCE: The Registered Manager has worked in the home for many years and has been the Registered Manager for approximately five years. She has finished the NVQ level 4 in Management and Care. Feedback from service users and staff was positive. Those asked stated they felt able to approach the Registered Manager for advice or support. The home has various ways to review the care offered in the home. Monthly Regulation 26 visits occur and reports are forwarded on to the CSCI. Service users, family and professionals are given surveys to complete and the Group Manager completes a report looking at a range of areas that are linked to whether the home is meeting the National Minimum Standards. The home has also begun devising a summary of the improvements the home has been working on and future aims and objectives. This summary will be available for the service users and their representatives. Each funding Local Authority also carries out an annual visit and the home usually receives a report following on from these visits. The Inspector viewed a range of health and safety records. Fire drills had been held at different times and at regular intervals. Risk assessments are completed on those service users who fail to respond to the fire alarm being set off. The home had completed a fire risk assessment and this is reviewed on an annual basis. The Inspector made a strong recommendation for the home to contact the local Fire officer to arrange for them to visit. This is in light of the new fire Regulations that were introduced in the latter part of 2006. The Registered Manager stated they would action this immediately. The Inspector also advised for the fire officer to view the home’s fire risk assessment to ensure it covers sufficient information. Water temperatures had been taken on a weekly basis and these were within an appropriate range. The home had an environmental risk assessment completed and this covered areas such as the lounge, stairs and bathrooms. Fire equipment, Gas Safety record, testing for Legionella and the Portable Appliance Test were all up to date. In the laundry room there are hot pipes that have warning signs on them and the laundry door has a warning sign on it for service users not to enter. However the laundry room door was not locked and the Inspector voiced their concerns to the Registered Manager who informed the Inspector that this door would be locked in the future. The home has a contract for mediation to be disposed of and clinical waste. Eastbury Nursing Home DS0000010930.V324906.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 Adults 18-65 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 3 x 3 x x 3 x Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation Schedule 2. Requirement Timescale for action 16/02/07 2. YA35 3. YA35 A signed health declaration must be completed and available for inspection, regarding each member of staff. 18(1)(a)(c)(i) There must be written evidence available regarding the induction new members of staff receive. 18(1)(a)(c) Mandatory training and any additional training must be booked and up to date for all members of staff. 28/02/07 30/04/07 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 YA17 YA42 Good Practice Recommendations It is recommended for a list to be available regarding the service users dietary requirements, such as likes/dislikes and any special dietary needs. It is strongly recommended for the local fire officer to visit the home to carry out an inspection, as the fire Regulations have recently been updated. The fire risk DS0000010930.V324906.R01.S.doc Version 5.2 Page 28 Eastbury Nursing Home assessment should also be viewed during this visit. Eastbury Nursing Home DS0000010930.V324906.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. 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