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Inspection on 06/06/05 for Eastbury Nursing Home

Also see our care home review for Eastbury Nursing Home for more information

This inspection was carried out on 6th June 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a group of staff that work well together in the interests of the service users. Leadership and management are consistent offering support and direction to the home. Service users feedback indicated that staff are caring and the home seeks to provide occupation and stimulation, through offering a variety of activities. The staff are keen to meet the individualised needs of the service users and acquire new skills to meet the complex needs of those living in the home.

What has improved since the last inspection?

Improvements have been made with regard to medication systems and these are more robust than at the previous inspection. The home has sought to address all the requirements made previously.

What the care home could do better:

The home must consider ways to consult with service users when completing or reviewing care plans. Where this is difficult the home must explore alternative methods to ensure all relevant people have their views noted on care plans. The home must ensure action is taken to minimise risk to service users and staff. Where maintenance issues are identified these must be addressed to prevent any incidents occurring. Quality assurance reports must be available within the home for service users and the CSCI.

CARE HOME ADULTS 18-65 Eastbury Nursing Home 12 Eastbury Road Northwood Middlesex HA6 3AL Lead Inspector Sarah Middleton Unannounced 6 June 2005 10.30AM th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Eastbury Nursing Home Address 12 Eastbury Road, Northwood, Middlesex, HA6 3AL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01923 823816 01923 823816 MD Homes Mrs Subiha Tabassum Hussein Care Home with Nursing 20 Category(ies) of Physical Disability, Learning Disability and registration, with number Mental Disorder of places Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: YES 1. Adults over 40 in need of general nursing. 2. Physical Disability. 3. Learning Disability. 4. Mental Health Problems. 5. Minimum Staffing Notice. Date of last inspection 18/10/04 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 Disablities, 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. There is a stair lift for those service users unable to manage stairs. The home has a spacious conseratory 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. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 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. A total of just under six hours, 10.30AM-4.20PM was spent on the inspection process. A tour was carried out of the home and service users plans, staff files and maintenance records were viewed. Seven service users and three staff were spoken with as part of the inspection process. It must be noted that it is sometimes difficult to ascertain the views of service users who have a variety of needs. The home had seventeen service users residing at the home when the inspection took place. One service user was on holiday, one was in hospital and there was one vacancy. All of the previous requirements were met and four new requirements were set at this inspection. What the service does well: What has improved since the last inspection? Improvements have been made with regard to medication systems and these are more robust than at the previous inspection. The home has sought to address all the requirements made previously. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 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. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 & 4. Service users are provided with information about the home. Service users are assessed prior to admission to ensure the home can meet their needs. Staff receive training to meet service users specialist needs. Prospective service users and their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: Service users, their relatives and representatives are provided with information regarding the home in the form of a Service Users Guide. This is informative and freely available. Pre-admission documentation was viewed; this had been updated to gather detailed information about prospective service users. This information provided a clear picture of the service users needs, including mental health or dementia care issues. In addition, a sample of hospital discharge summaries and care management assessments were seen. The home confirms in writing if they can meet the prospective service users needs. There is a mixture of qualified and unqualified staff who receive training on specific areas to ensure the complex needs of service users can be met. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 9 The Registered Manager said that wherever possible, prospective service users are encouraged to visit the home and meet other service users and staff. If they could not visit then their representative could visit on their behalf. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 & 9. Care plans provide detailed information about identified service users needs. There were shortfalls in evidencing if the home had consulted with service users when devising and reviewing care plans. The home encourages service users to make informed decisions about their lives and there are opportunities for them to offer their opinions about the home in service user meetings. Detailed risk assessments are in place that aims to cover the main aspects of each individual’s life. The home seeks to balance encouraging service users to have choices/ make decisions against minimising risk. EVIDENCE: Individual service user plans were available and samples were viewed. Overall these were comprehensive and detailed how the service users’ identified health, personal and social care needs would be met. Service users plans were up to date and had been reviewed monthly or whenever there was a change in the service users needs. Assessments for nutritional screening and personal care needs were in place. The Registered Manager or Deputy Manager completes the care plans, consulting with keyworkers to ensure information is up to date and correct. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 11 There was no evidence on the care plans viewed that staff had consulted with service users when devising the plans and reviewing them. The home seeks to promote service users rights to make decisions. It was noted on one care plan that a service user had requested more privacy. The home provides the opportunity for service users to access advocates, should they require independent support. Where possible service users manage their own finances, where this is not possible the home manages their money. Service users have a meeting every few months to contribute how they are feeling and any issues they might have about the home. Minutes of these meetings are documented and were viewed. Risk assessments were completed on the sample of care plans viewed. These were detailed outlining information on the main risks and how to manage them. One service user has been re-assessed and can now go out locally unaccompanied. Systems are in place to monitor this plan, to ensure the service user and the public are safe. Another service user has attempted to abscond several times. The home carries out regular checks day and night to ensure this service user does not leave the home unaccompanied. Fire door exits are fitted with an alarm that is activated if they are opened. The home responds promptly to any absences in the home. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 & 17 Service users have the opportunity to be as independent as possible, with risk assessments in place. Service users have the opportunity to take part in activities both inside and outside of the home. Overall these are varied and provide stimulation to those needing this and seeking it. Family contact is encouraged to maintain relationships. Meal provision and mealtimes are well managed. EVIDENCE: Where possible, service users are encouraged to be as independent as possible. Assessed needs are reviewed and where changes occur this is noted on care plans, to ensure the service user is fully supported in gaining further independence. One service user enjoys walking every day unaccompanied and their care plan indicates they are able to go out alone. Religious needs are noted on care plans and the local church visits the home on a regular basis. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 13 Due to the needs of the service users they are not able to gain employment. Those that want to can access the local days centres, approximately six service users currently attend day centres. Others, that are able, take part in activities offered within the home. Service users spoken with said they visit the local libraries, occasionally the church, shops and the pub to occupy their leisure time. This is primarily with staff support. The home can rent transport, if they are organising a group trip out for the day. The home has an activities co-ordinator who visits the home two or three times during the week. They seek to offer additional activities for the service users. Service users can also have a massage, from a qualified masseuse and their hair styled by regular visits from a hairdresser. Family contact and visits to the home by family or friends is flexible. One service user visits their mother in a local residential home daily. There were no visitors to the home on the day of the inspection. Those service users, who can manage their own mail, receive it directly. Staff were seen to interact positively with the service users, talking to them throughout the inspection. One service user enjoys sitting apart from people and this is respected. Interaction with this service user took place between staff and other service users. The home has a four-week rolling menu. Choices are noted and as are any changes to the set menu. Temperatures are checked daily for the fridges and freezer and food had dates of opening on them. Lunchtime was observed and was unhurried. Staff fed one service user in a sensitive and appropriate manner. Food seen on the day of the inspection looked well presented. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 & 21 Staff respect service users dignity and privacy. Personal care is offered in a sensitive manner. Service users health needs are met and referrals are made to relevant professionals where there are specific health needs outside of the home’s remit. Thus ensuring service users health and welfare is maintained. Robust medication systems are in place to safeguard service users. The home, where possible, seeks the wishes of service users to ensure their rights are upheld in the event of their death. EVIDENCE: Staff provide personal support ensuring they respect the service users privacy and dignity. All personal care is offered in private. Care plans note who requires support from staff and what the level of support needs to be. Service users are encouraged to choose their own clothes and when they get up / go to bed. One staff member said a service user chooses to cut their own hair. Local Community Psychiatric Nurses and the Mental Health Team provide specialist support and advice to the home. Regular reviews are held for those service users who require their mental health and medication to be monitored. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 15 Health records were up to date noting when service users had seen GP’s, Dentists or Dieticians. A service user, who has a catheter, had a detailed care plan recording how to care for this particular need. Records also noted service users appetite and weight. Observations charts were held on those care plans viewed, these recorded blood pressure and pulse. Samples of the medication administration records were viewed. These were correctly completed. All medications were appropriately and securely stored. Liquid medications had the date of opening written on them. In addition there was a list of signatures of all qualified staff able to administer medication. The home did not have any controlled drugs at the time of the inspection. On care plans, where addressed, it is noted service users’ preferences for care following their death. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home has a satisfactory complaints procedure, where service users spoken with felt confident their concerns would be taken seriously and addressed by the home. Systems were in place for the protection of vulnerable adults. Staff spoken with were aware of POVA procedures and what to do if they suspected a POVA incident. EVIDENCE: The home has a complaints procedure in place. There have been no complaints recorded or made since the previous inspection. The CSCI had not directly received any complaints. Service users spoken with said they would go to the Registered Manager if they had a complaint. They also felt any complaint would be listened to and acted on. The home has a clear procedure for the protection of vulnerable adults (POVA) and this dovetails with the Local Authority’s POVA procedure. Staff working at the home had recently received training on POVA issues from the Local Authorities POVA co-ordinator. There had been one POVA investigation since the last inspection. Procedures had been followed and the relevant professionals notified. However, this is still unresolved due to the staff member leaving their employment and the home not being able to undertake necessary investigations with the staff member. Therefore the Registered Manager must consider whether to close the case. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 & 30 Overall there is a homely environment for service users. Service users have privacy if they share a bedroom, through the use of screens/curtains. There is sufficient communal space to provide service users opportunities to be with others or alone. Equipment is available for those needing additional support. EVIDENCE: A tour of the home was carried out and a sample of rooms viewed. These were being satisfactorily maintained. Furnishings and fittings were of good quality and the home was bright and clean and free from offensive odours. The home is close to a range of shops and transport to access the main local towns. A sample of bedrooms were viewed and these were personalised. There are five double rooms, and care plans documented service users agreement to share a bedroom. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 18 Although this should be regularly reviewed to ensure the service users are able to make an informed choice about sharing a bedroom. Service users can have a key to their bedrooms and they each have a lockable space within their bedrooms. The assisted bathrooms and toilets viewed were satisfactory, although as noted later in the report, the water for the hand basin in one communal toilet exceeded maximum temperatures. There are plans for the home to have two shower rooms fitted. There is a large lounge/dining area, which is divided into two sections. In addition there is a large conservatory for service users to access. The home has a stair lift for service users to access the first floor, however all service users with bedrooms on the first floor can use the stairs. The Registered Provider has long term plans to install a passenger lift. Policies and procedures for the control of infection were available. Protective clothing is provided and was used during the inspection. There is a separate sluice room and there are plans to extend the home to provide a new sluice and laundry room. Clothes are labelled to ensure service users personal items do not go missing. Those service users asked said they were happy with the laundry facilities. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 & 36. There is continuity of care offered to service users as the home has a stable staff team, who are aware of their individual roles. Staff have the opportunity to develop skills and knowledge through mandatory training and the opportunity to study the NVQ courses, or through adapting their qualification as a nurse. Staff receive regular one to one support through supervision from management. Through offering this form of support and guidance staff can reflect on their practice. There are robust systems in place for the recruitment of staff, which promotes the safety of service users. EVIDENCE: All staff receive job descriptions, outlining their role within the home. Staff interviewed were aware of their roles, in particular if they were not qualified nurses. They were aware of what aspects of work they could undertake and what they could not. Two staff have NVQ level 2 and many staff are adaptation nurses, seeking to obtain the qualification to work as qualified nurses in England. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 20 The home has a rolling programme of adaptation nurses, whereby qualified nurses support and supervise them in their role within the home. The Registered Manager is a Registered General Nurse, as is the Deputy Manager. There is always a qualified nurse on each shift ensuring an effective and competent staff team supports the service users. There were no staff vacancies at the time of the inspection. The Registered Manager said staff meetings were held every two or three months. Minutes were seen for these meetings. The staff employment files viewed contained details of the applicants completed application forms, Criminal Record Bureau checks, identification and references. The home provides mandatory training and staff spoken with confirmed they received training on all aspects of care and health and safety within the home. Staff are inducted and there is evidence of this in the home. The Registered Manager and Deputy Manager supervise all the staff working in the home. There is a supervision policy in place and this is offered every six weeks. A sample of supervision notes were seen and staff spoken with confirmed they found supervision supportive. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 42 & 43 The home is well managed and the Registered Manager has an open style of management. There are detailed policies and procedures that all staff are requested to familiarise themselves with in order to safeguard service users. The quality assurance report was not available, this must be carried out in order to review and improve the care provided. Service users and their representatives must be able to contribute their opinions and feel they are a part of the review of the home. There were shortfalls in one of the servicing records and the monitoring of water temperatures in one area of the home. The health and safety of service users and staff must be paramount at all times. Action must be taken when areas need to be rectified. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 22 EVIDENCE: The Registered Manager is a qualified nurse and has successfully completed NVQ level 4. She has worked at the home for several years and is aware of the role of a Registered Manager. Staff spoken with said the management was supportive and approachable. The Registered Manager was observed interacting positively with both service users and staff. There are clear lines of accountability within the management structure of the home. The Registered Manager said there had been a quality assurance review. However there was no evidence that this had taken place. A sample of policies and procedures were viewed. Staff sign when they have read these, although this list did not represent all staff members. Policies and procedures are reviewed on a regular basis. Servicing records were viewed at random. The Portable Appliance Testing records were not up to date. All other servicing records seen were up to date. The home holds regular fire drills and fire alarms and equipment are tested on a regular basis. The home has a maintenance book to record all jobs needing attention. The home also employs a maintenance person to monitor the work needing attention within the home. Water temperatures are taken, however the water in the ground floor communal toilet was too hot. Discussions took place to lock this toilet until the problem could be rectified. A business plan was viewed and no problems were noted. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Eastbury Nursing Home Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 x 2 3 G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 24 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 6 Regulation 15 Requirement Timescale for action 1/8/05 2. 39 24 3. 4. 42 42 13 (4) (a) & 23 (c ) 13 (4) (a) (c ) The Registered Person shall consult with the service user, or where this is not possible, their representative, when devising or reviewing their care plans. The Registered Person shall 30/9/05 establish a quality assurance review of the home and make available to both the CSCI and to service users a report of the review. The Registered Person shall 29/7/05 ensure servicing records are up to date. The Registered Person shall 10/6/05 ensure that water temperatures are regulated and do not pose a risk to service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 2 Good Practice Recommendations The home should consider placing the written confirmation, which agrees the home can meet the needs of a prospective service user, on care plans as well as G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 25 Eastbury Nursing Home 2. 40 being held at the head office. The home should ensure all staff view and sign the current policies and procedures held within the home. Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 Eastbury Nursing Home G61-G10 S10930 Eastbury NH V228376 06.06.05 Stage 4.doc Version 1.30 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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