Inspection on 24/10/06 for Elizabeth Fleming Nursing Home

This inspection was carried out on 24th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Elizabeth Fleming Nursing Home 22/07/08

Elizabeth Fleming Nursing Home 09/05/07

Elizabeth Fleming Nursing Home 24/01/06

Elizabeth Fleming Nursing Home 26/04/05

Elizabeth Fleming Nursing Home 05/10/04

Elizabeth Fleming Nursing Home 26/05/04

Similar services:

The Highlands

Blenheim House

1 Lanark Close

Beaconsfield Court Care Home

Ann Charlton Lodge

The Gardens Care Home

Westmoor View Nursing Home

Ashlea Mews Residential Home

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

CARE HOMES FOR OLDER PEOPLE Elizabeth Fleming Nursing Home Off Market Street Hetton Le Hole Houghton Le Spring Tyne & Wear DH5 9DY Lead Inspector Irene Bowater Key Unannounced Inspection 24 October and 8 November 2006 09:00 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 Elizabeth Fleming Nursing Home DS0000018191.V309153.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. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth Fleming Nursing Home Address Off Market Street Hetton Le Hole Houghton Le Spring Tyne & Wear DH5 9DY 0191 526 2728 0191 526 6187 elizabethfleming@highfield-care.com 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) Southern Cross Care Homes Limited Julie Gray Care Home 36 Category(ies) of Dementia (9), Dementia - over 65 years of age registration, with number (28), Mental disorder, excluding learning of places disability or dementia (8), Mental Disorder, excluding learning disability or dementia - over 65 years of age (29), Old age, not falling within any other category (1), Physical disability over 65 years of age (9) Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. During the day 1 x RMN and 3 care staff on the 20 place nursing unit, 1 x 2nd level 1nurse and a care assistant on the 8 place nursing unit and 1 senior care assistant and a care assistant on the 8-place personal care unit. During the night will be 1 x RMN and 3 care staff. These staffing levels will be exclusive of any additional staffing arrangements agreed in individual service users contracts. The manager will be supernumerary to the staffing complement and an RMN will be on duty throughout the 24-hour period. The DE service user category includes one place for one particular service user The MD (E) service user category includes one place for one particular service user. 24th January 2006 2. 3. 4. Date of last inspection Brief Description of the Service: The Elizabeth Fleming Nursing Home is a 36-place bungalow style home. The home provides personal and nursing care for older and younger people with either dementia type illnesses or mental health needs. Originally the Elizabeth Fleming nursing Home opened in 1994, as a 40-place home for older people with dementia type illness that required nursing care. In February 2002 the registration changed so younger adults could be cared for and during this process five places were de-registered and could not be used. Two 8-place units and one 20-place unit have been created. The home is now registered for one unit, which can provide care for 8 younger adults who have nursing needs and a mental health or dementia-type illness. One unit can provide care for 8 older people with personal care needs and a mental health need or dementia-type illness. The 20-place unit can provide nursing care for older people with a mental health need or dementia-type illness. The home is at the top of Market Street, not far from the main part of Hettonle-Hole. It is opposite the post office and a range of shops. A bus stop is close to the home. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 5 The home has developed a Statement of Purpose and Service User Guide that informs people of the aims and objectives of the home. These are readily available in the home. The current fee ranges for this home are from £374 to £412. The nursing care element is extra and is set nationally. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over two days. The registered manager was not available on the first day of the inspection and some information and record keeping needed to be discussed with her. Therefore a second visit to the home was arranged. During the two days the inspector spent time with the Registered Manager, staff, residents and visitors. The inspector looked around and talked to residents and staff, and saw the contact between them. Time was also spent checking the cleanliness, maintenance and decoration of the home. A number of documents were looked at including, training, maintenance, catering, medication, financial, recruitment, health and safety, and complaint records. A complaint about lack of suitable bathing facilities had been received before the inspection and these concerns were looked at during the inspection. The company had been trying to resolve the problem for some time. The home confirmed the following day that both baths had been repaired. The number of useable bathrooms was looked at again on the second day of the inspection. What the service does well: The staff have all the necessary information before any resident moves into the home to ensure they can meet their needs. There is communication with other professionals to ensure staff know what the residents health needs are. The staff make sure that the residents rights to privacy and dignity are maintained. The care staff are kind and caring and have an understanding of residents health care needs. Residents who are able can make decisions about their lifestyle. They said they “liked the home”, “the staff were nice” and “the food is good”. Visitors said, “they are well looked after” and “they get loads of food”. One relative said “it’s homely with good staff we have no problems”. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 7 Visitors are made welcome and there are good links with the local community. Residents and visitors said they would be able to use the complaints procedure if they had a concern. ‘’ The staff receive the training they need to care for the residents’ needs. The home is clean, homely and a comfortable place for people to live. What has improved since the last inspection? What they could do better: Although there have been improvements made to the care plans, work is still needed to ensure they are clear and detailed. The qualified nurses must make sure that they follow medication requirements. Issues that needed immediate attention were identified at the time of inspection. These were poor practices and poor record keeping in regard to safe administration of medicines. The qualified nurses must make sure that these are dealt with and sorted out. The home has completed an action plan which sets out how they intent to improve. The manager needs to look at how meal times can be managed better for those residents who need a lot of help. Staffing levels at peak times need to be looked at so that residents can maintain choices and autonomy. Further specialist training is needed to make sure staff have a good understanding of the residents’ holistic needs. In order to keep a safe and comfortable home repairs are needed to doors and some lounge furniture. The redecoration of the home also needs to continue. The home must make sure that any repairs are carried out as soon as possible so that the residents’ quality of life is not affected. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 8 The registered manager needs to continue to promote good care practices and make sure residents rights are maintained so that they can maintain control over their lives continues for as long as possible. The registered manager must make sure that the nursing staff maintains clear accurate records. 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. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 9 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 Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4. Standard 6 is not applicable. The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Prospective residents are given information about the service provided before admission. This ensures that they can make informed choices. The admission assessments and procedures ensure the residents care needs will be met. EVIDENCE: The home has developed a Statement of Purpose and Service User Guide, which gives information about the home. The Guide includes information about the accommodation, the staff, how to make a complaint and a copy of the recent inspection report. The Guide also includes information about how residents’ rights will be respected regardless of age, gender, sexual orientation, race and religion. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 11 None of the information is in large print or pictorial style although the registered manager confirmed that there are plans to put the information on audiotape. Seven care plans looked at showed that the manager carries out comprehensive assessments before any resident is admitted to the home. The care managers and the nurse assessments were also available. Information is also available about residents’ previous lifestyles and how this will help residents to settle into the home. Once the assessment has been completed the prospective resident receives a letter to confirm that the home can meet their needs. Elizabeth Fleming Nursing Home DS0000018191.V309153.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9.10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The care planning systems does not always provide staff, residents and their representatives with all the information they need to meet resident’s needs. The health needs of all residents are being met. The nursing staff were not ensuring that residents received their medication safely as prescribed and in line with safe practice guidance. Personal support promotes residents right to privacy and dignity. EVIDENCE: Each resident has a care plan that has been developed with the help of information gathered before they came to live in the home. There are a number of assessment tools in place around pressure care, nutrition, moving and handling, mental health and dependency. Seven care plans were case tracked and there is inconsistency around how often these plans are reviewed and up dated. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 13 A sample of care plans had not been evaluated monthly. One resident who was admitted in September 2006 did not have the physical and social assessment completed. The risk assessments and initial care plan were completed on admission but have not been evaluated since. A care plan relating specifically to the management of wounds was detailed and up to date. For example staff were given clear guidance around skin integrity and the type of treatment for each individual specific wound care needed. The residents have access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. Advice is sought from, psychologists, occupational therapists, tissue viability specialists, speech therapists and continence advisors. Care management reviews are regularly held with input from residents, their representatives and the multidisciplinary team. The home has comprehensive medication policies and procedures for staff to use and uses a monitored dosage system for the administration of medicines. Some medicines cannot be dispensed in a blister pack and these medicines are supplied in bottles or packets. Liquids are obviously supplied in bottles. The home has a central treatment room. There are three trolleys used in the home, one for each of the units. These are used to administer the current medicines to the residents. Other stock is held securely in locked metal cupboards in the treatment room. A random inspection of the medication administration record showed that there were discrepancies. There was an excess supply of medication and excess medication was being returned to the pharmacy at the end of the month. The registered manager had previously identified problems with the safe administration of medicines and these concerns were recorded in the minutes of staff meetings. An immediate requirement was left at the home to make sure that the identified problems were put right within a given timescale. A letter was also written to the registered persons stating the concerns and requiring a letter by return of how they were putting these problems right. There is a list of signatures used by the nurses when recording medicines have been given, so that it is easy for the home to identify who has made any errors. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 14 None of the residents self medicates. Care was given in a discreet manner with staff knowledgeable about residents’ preferences. Nursing care and treatment was carried out in the privacy of residents’ own rooms and staff were observed to use the term of address preferred by the resident. None of the residents share a room. Elizabeth Fleming Nursing Home DS0000018191.V309153.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Social activities provide stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with opportunities to maintain their previous lifestyles. Residents are supported to make choices and take control over their lives as far as they are able. There is a varied menu and special diets can be catered for. EVIDENCE: The home has an activities organiser who works for 30 hours a week. There is a large notice board in the reception area, which displays various activities both within and outside of the home. On the first day of the inspection the home was preparing for a Halloween party. The residents have also enjoyed taking part in the summer fete, visiting local shops and enjoying in house movies. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 16 The residents on the younger persons unit regularly go out, some prefer to spend their time in the lounge, smoking room or the privacy of their own room. They have access to a computer and they can enjoy a game of billiards in their themed “pub”. The residents on the personal care and nursing care unit have more limited opportunities because of the nature of their needs. Residents on the personal care unit are supported to maintain their independence by using the kitchen facilities and being involved in daily activities with the staff. The residents on the nursing unit have complex health care needs and many are unable to take part in group events. During the two days of inspection there was little evidence to show that staff take into account the residents individual choices or wishes based on their current and previous lifestyle. The residents were sat in the lounge; the television was on with the sound turned down. There was little in the way of general interaction with the member of staff who was delegated to supervise this room. The staff were kind and had an understanding of residents physical needs. The registered manager has completed a training course based on the Alzheimer’s Society’s training “Yesterday Today and Tomorrow”. Once the staff team have received the training the daily life of residents should improve. Relatives and friends are made to feel welcome and know that they can visit at any time. There were visitors on both days of inspection and the staff took time to welcome them and discuss events with them. The visitors were complimentary about the staff team saying, “they are good staff”, “it’s homely with kind staff”, “and they tell me what is going on”. Residents have been encouraged to bring small items of furniture and other belongings with them, making their rooms individualised and reflective of their lifestyles. The staff support residents who need help with their finances. Information about advocacy is readily available should anyone need independent advice. The home has dining rooms on each unit. The younger persons and personal care unit have kitchenette facilities where residents can assist with domestic type activities. The meals on these units are served plated from “hot trolleys” which are sent from the central kitchen. The dining room on the nursing unit is large and the meals are served directly from the kitchen. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 17 On the first day of the inspection the lunchtime meal consisted of Liver mashed potatoes, cauliflower, carrots and gravy. The alternative was fish fingers, chips and peas followed by chocolate sponge and custard. The portion sizes were huge, served on small dinner plates. Soft diets were served in dessert bowls with all of the meal blended, which then resembled thick or thin gravy. None of the menus were in display and none of the residents or staff were sure what was for lunch that day. The tables were not set with tablecloths, appropriate crockery, cutlery condiments or napkins. The staff on the younger persons and personal care unit had time to spend with the residents and the mealtime was a fairly pleasant occasion. The residents on the nursing unit have both physical and mental health care needs with at least ten needing two staff for moving and transferring from one area to another. Due to their illness residents are not able to sit for any period of time to enjoy their meal and several were up and down from the table or leaving the dining room and leaving their meal unfinished. Due to the high needs of the residents it was very pressured and a protracted affair. The staff confirmed that meal times could take over an hour with some of the residents having to wait some considerable time for assistance. Staff followed good practice and supported one person at a time whilst verbally prompting others but there were more people who needed a lot of staff support, than staff available to undertake this role. One the second inspection day there was evidence that some practices at mealtimes had changed. All of the dining tables in all units were set with tablecloths, napkins and cutlery. No condiments were on the table in the nursing unit nor were residents offered salt, pepper or sauces. Juice was available on a trolley in the nursing unit but the tables did not have glasses or cups and saucers. Several residents did not have a drink with their meal. The lunch choices were roast turkey, Yorkshire puddings, sprouts, cabbage, turnip and mashed potatoes or egg, chips and beans. Dessert was fruit cocktail and cream. Again the portion size was huge served on small plates. The presentation of the soft diets had improved with staff using appropriate moulds to separate the food into portions. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 18 Again the staff followed good practice and supported one person at a time whilst verbally prompting others but there were more people who needed a lot of staff support than staff available to undertake this role. Residents again waited for some time for help whilst others did not finish their meal. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The complaints procedures are clear. Residents and relatives are confident that their views are listened to and acted upon. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: The home has detailed complaints procedures, which clearly sets out how and to whom to make a complaint. The procedure is available in the Statement of Purpose, the Service User Guide and is displayed in the home. Relatives said they would be able to use the procedure but “didn’t need to as there was nothing to complain about” and “they always see to everything straight away”. There have been four complaints since the last inspection one of which was referred to the Commission. All have been resolved. There are procedures in place to protect vulnerable adults .The staff have received training and know when to involve external agencies. The links include adult protection teams, police and the Commission. There have been two referrals since the last inspection which have been satisfactorily resolved Elizabeth Fleming Nursing Home DS0000018191.V309153.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The home is comfortable and clean and meets the needs of the people who live there. Some areas require improvement. EVIDENCE: This is a single storey building, which has been developed into three separate units. The units are self-contained with dining rooms, lounges, smoking rooms and bathing and toilet facilities. All have access to the garden and patio area. On the first day of the inspection the sensory room was out of use and cluttered with broken items, washing machine, boxes of continence aids and artificial Christmas trees. By the time of the second visit this room was still not in use but had been cleared of obsolete items. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 21 There has been damage to the perimeter wall .A risk assessment is in place and the home have asked for a structural report from the council as it is their property. The communal areas are homely and generally nicely furnished. The lounge chairs in the nursing unit are showing signs of wear with black marks on the arms and several of the seat cushions are splitting at the seams. There have been problems with the assisted bathrooms for some time with two being broken and out of use. On the first day of the inspection the company was trying again to get them repaired. They were both repaired and in working order within twenty-four hours. None of the bedrooms have en-suite facilities but there are toilets close to bedrooms and communal areas. The home was clean and fresh. The laundry facilities are small and it is not possible to have a clean and soiled area. During the first day of inspection the access to the hand wash sink was blocked by bins of dirty washing. The laundry area was more organised by the second visit to the home. The sluice areas on the first inspection day were cluttered and the disinfector inaccessible. There was no liquid soap or paper towels to enable proper hand washing. Again by the time of the second visit these areas were clean and tidy with hand washing facilities available. The light cords have become knotted and grimy. In order to minimise the risk of cross infection these need to be replaced to enable staff to clean them on a daily basis. On the second inspection day it was confirmed that the bins had appropriate lids. Elizabeth Fleming Nursing Home DS0000018191.V309153.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to the service. The current staffing levels currently meet residents needs. The arrangements for training and recruitment ensure that residents are protected and staff are competent. EVIDENCE: The home has three units, which are staffed separately. The eight bedded younger persons unit has 1 carer and a qualified nurse during the day. The eight bedded dementia care unit has 1 senior carer and 1 carer during the day. The dementia care unit with nursing has 3 carers and 1 qualified nurse during the day. Overnight there is 1 qualified nurse and 3 carers. There were sufficient ancillary staff on duty including laundry, catering, administration, maintenance and an activities organiser. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 23 The levels of dependency on the nursing unit were high with several residents needing the assistance of two staff for all of their needs. This meant some residents had to wait in turn to be assisted to the toilet, dining room and to have help eat their meals at their leisure. The dependency levels should be constantly reviewed to make sure there are enough staff available at peak times. The home continues with NVQ level two training with 80 of staff holding this qualification. Five staff files and training and development records were inspected. The records for recruitment were satisfactory. There was evidence of Criminal Record Bureau checks, Protection of Vulnerable Adult checks, two written references, proof of identity, professional identity numbers for registered nurses and completed signed induction programmes. Evidence from the files and from discussion with staff confirmed that they have received training in safe working practices, protection of vulnerable adults, and prevention of pressure damage and dementia care training. The registered manager completing training in “Yesterday Today and Tomorrow” and introducing a “Person Centred Approach” to care delivery. Elizabeth Fleming Nursing Home DS0000018191.V309153.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The manager is appropriately qualified to manage the home. During her absence there has been a lack of leadership and direction given to staff. The systems for consultation and quality monitoring are satisfactory. Residents personal accounts are managed to ensure their best interests are protected. Some improvements are needed to in house maintenance. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 25 EVIDENCE: The registered manager is experienced and competent to manage the home. She continues to update her knowledge to improve the service for the residents who live in the home. Recently she has been taken out of the home and the direct leadership and supervision of staff has therefore been inconsistent. This has lead to some poor record keeping especially in regard to recording of medication. Regular staff meetings are held with minutes recorded. There are quality assurance and quality monitoring systems in place. Monthly visits by the regional manager take place and a report of the areas audited is available. The home has clear systems in place to make sure residents personal money is kept safe. Receipts were available for all transactions, which could then be crossreferenced to the records. Reconciliation of the accounts takes place weekly and residents are encouraged to have their own bank accounts. It was not possible to audit individual monies as money is held in a central non-interest bearing account. Staff have had training in safe working practices with records kept. Fire training is completed every three months for night staff and six months for day staff. Accidents are clearly recorded and the manager completes monthly accident analysis to examine and track any trends. A fire risk assessment is available and is up to date. Weekly in house health and safety checks available and signed and a health and safety audit was completed in July 2006. The problems with the perimeter wall are being dealt with and a risk assessment is in place. There is some damage to doors where the handles and locks have been changed. These doors need repair prior to repainting. Elizabeth Fleming Nursing Home DS0000018191.V309153.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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 3 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 2 2 YES Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15(2) 12(2) Sc 3 3q Requirement The registered persons must ensure that all care plans set out in detail the action to be taken by staff to ensure all aspects of the health, personal and social care needs of residents are met. The registered persons must ensure that the plans are reviewed at least monthly and are updated to reflect any changing need. The registered manager must ensure the immediate requirements are actioned. The registered manager must ensure that records of all medicines received, administered, returned or disposed of are kept to ensure there is no mishandling. The registered persons must ensure that the requirements of the Medicine Act 1968,the Royal Pharmaceutical Society, the Misuse of Drugs Act 1971 and the requirements of the Nursing and Midwifery Council are followed at all times. The registered persons must ensure that the light cords are free from knots and easily cleanable. DS0000018191.V309153.R01.S.doc Timescale for action 31/01/07 2. OP9 12.13.17 25/11/06 3 OP26 13,23 31/01/07 Elizabeth Fleming Nursing Home Version 5.2 Page 28 4 OP38 12,13,23 The registered person must ensure that liquid soap and paper towels are available in all areas to ensure effective hand washing. The registered persons must ensure that repairs are carried out on internal doors. 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP15 OP19 OP20 OP27 Good Practice Recommendations It is highly recommended that the design of the dining room be reviewed. Consideration should be given to extending the garden to include the disused parking spaces at the side of the home. (Required at previous inspections) It is highly recommended that the lounge chairs in the nursing unit be repaired or replaced. The dependency levels should be constantly reviewed to make sure that sufficient staff are available at peak times. Elizabeth Fleming Nursing Home DS0000018191.V309153.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Shields Area Office St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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