Inspection on 09/05/07 for Elizabeth Fleming Nursing Home

This inspection was carried out on 9th May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elizabeth Fleming Nursing Home 22/07/08

Elizabeth Fleming Nursing Home 24/10/06

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 9th May 2007 8:00am 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.V335985.R02.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.V335985.R02.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.V335985.R02.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 l nurse 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. One service user over 65 years may reside within the MD unit. 2. 3. 4. 5. Date of last inspection 24th October 2006 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.V335985.R02.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 £387 to £413.50. The nursing care element is extra and is set nationally. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 24 and 8 November 2006 • How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service & their relatives, staff & other professionals The Visit: An unannounced visit was made on 9 May 2007 During the visit we: • talked with people who use the service, relatives, staff, the manager and visitors • looked at information about the people who use the service and how well their needs are met • looked at other records which must be kept • checked that staff had the knowledge, skills and training to meet the needs of the people they care for • looked around the building to make sure it was clean, safe and comfortable • checked what improvements had been made since the last visit • we told the manager what we found. What the service does well: The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. Staff involve the residents, their representatives and other professionals in the care planning to makes sure their needs can be met. The staff have formed good relationships with the residents and make sure their rights to privacy and dignity are met. There is good communication with other professionals to ensure peoples health care needs are met. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 7 Staff involve the residents, their representatives and other professionals in the care planning to makes sure their needs can be met. Relatives said, ● “the home and the staff are good” ● “ this is my relatives home” ● “I am more than happy with the care in the home”. The meals are nutritious, nicely presented and choices are available. Relatives said , ● “there are always a choice of food” ● “it’s always nicely cooked” Visitors are made welcome and there are good links with the local community. Residents and relatives said they would be able to use the complaints procedure if they had a concern. The activities organisers work hard to provide activities inside and outside of the home. The staff receive the training they need to care for the residents needs. The recruitment policies are followed. The home is clean, homely and a comfortable place to live. What has improved since the last inspection? The care plans have been improved and now give detailed information about all aspects of individuals needs. Staff now follow all medication requirements. This makes sure people receive their medication safely. Improvements to the environment continue to take place. This will help people with dementia find their way around the home and keep some independence. The council has repaired the perimeter wall. The gardens have been landscaped and planted with a range of bedding plants for the residents to enjoy. Staff training continues so that all staff can give a person centred approach to care delivery. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 8 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. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.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.V335985.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information about the service before being admitted. This means that they can be sure the home can meet their individual needs. The admission assessments ensure the residents care needs will be met. EVIDENCE: The service user guide makes sure people who use the service have all the information they need to make choices about the home. The guide includes information about how peoples’ rights will be respected regardless of age, gender, sexual orientation, race and religion. The guide can be available in different styles such as Braille and audiotape. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 11 All people who use the services have an agreed contract. They give information about any charges in the home. Care plans show that the manager carries out comprehensive assessments before any resident is admitted. The care managers’ and nurse assessments were also available. Information is also available about residents’ previous lifestyles, including background, cultural, religious or other needs and how this will help residents to settle into the home. The assessment looks at what each person can do to take of themselves and what support they will need with the tasks of daily living and personal and health care. Where possible the relatives and representatives are involved in this process. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans are comprehensive and person centred this ensures people’s needs are recognised and fully met. Health and personal care is well met so that the care people receive is based on their individual needs. Robust systems for the administration of medicines are in place and ensure that people using the service receive their medication safely. A good level of personal support is in place which promotes peoples rights to privacy and dignity. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 13 EVIDENCE: All of the plans were clearly set out and up to date. Accredited assessments tools for the prevention of pressure sore and wound care, moving and assisting, catheter care, continence promotion, nutrition and mental health status were completed and reviewed and updated monthly. All of the care plans are regularly reviewed and updated according to changes in social, personal and health care needs. Residents who have reduced appetite or low weights are regularly weighed and intervention sought from dieticians. Their recommendations are acted upon and the care plans updated as necessary. Up to date information regarding changes in wound care is documented on a regular basis and regular reviews take place with residents’, their relatives and care managers to make sure the home is still meeting their needs. 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. There are appropriate pressure relieving devices available to support the staff and residents in daily activities. Advice is sought from, psychologists, occupational therapists, tissue viability specialists, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. Medicine storage is appropriate in secure trolleys or British Standard, metal cupboards. As well as being lockable, the trolleys are anchored within the clinical area by a secure chain and lock. The window to this room is secured with well-fixed metal bars. The clinical area is compact but it is secure. The room and storage is kept tidy and clean apart from the sink, which is stained due to a damaged and worn surface. A monitored dosage system is in use. The Medicine Administration Records (MAR) charts for all three units were examined. The level of recording was good and omission codes were used appropriately. Photographs were attached to the MAR charts to help to confirm the service users identity. There were no gaps in the records and specimen signatures were available. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 14 The nursing staff carry out a daily audit of medication stock and records of this were also available. The Controlled drugs were kept in an appropriate cabinet with a visual alarm on the wall outside the room. The records were examined and two medicines (Temazepam and Phenobarbitone) were recorded as controlled drugs. The records were accurate and a stock check confirmed this. The drug fridge is of an approved type and was locked. Temperatures are recorded daily, of the inside of the fridge, and also the ambient temperature of the clinical room. There was a good rapport between staff, residents and relatives, which was friendly and professional. Care was delivered in private and staff were seen to knock on doors and wait for permission before entering. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported to take part in a range of social activities, which provides 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 well supported to make choices and take control over their lives. Choices of nutritious and appetising meals are available to ensure individual dietary needs and preferences are met. EVIDENCE: The home has a designated activities organiser who plans events both within and outside of the home. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 16 There is a large notice board in the reception area, which displays the various activities that take place both inside and out of the home. Life histories are recorded for each person on admission and this helps the staff support residents to maintain their preferred lifestyle. Activities include, one to one, home skills, music, arts and crafts, films and various outings. The people who live on the younger persons unit go out regularly with staff and their relatives. They have access to a computer and can enjoy a game of billiards in their themed “pub”. People living on the personal care unit are supported to maintain their independence by using the kitchen facilities and being involved with daily tasks with the staff. The people living on the nursing unit have complex health care needs. Many are unable to take part in group events and need to be involved in daily events on an individual basis. Once all staff have completed the training “Yesterday Today and Tomorrow” a more person centred approach to daily life should happen. Visitors were seen to come and go throughout the inspection. They are able to use the lounges or residents bedrooms for visits. It was confirmed that there are no restrictions regarding visiting times. Visitors said “the staff are good” and “its home for my relative”. Information about advocacy is available in the home. Residents have brought small items with them making their rooms personalised and reflective of their previous lifestyles. The home has dining rooms on each unit. Two units have kitchenettes where people can assist with domestic type activities if they wish. Meals are sent from the kitchen in a “hot lock” and served plated by the care staff. The large dining room on the nursing unit is next to the kitchen and meals are served, plated, through the hatch. The dining tables in all units were suitably set for both breakfast and lunch. Several of the residents were up early and were given tea and biscuits before breakfast was ready. There were choices of cereal, juices, cooked breakfast, toast, bread and preserves. Hot and cold drinks were readily available at mealtimes and on demand during the day. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 17 Choices for lunch were, Lamb, Yorkshire pudding, turnip, sprouts, carrot and mashed potatoes or pasties, chips and peas. Desert consisted of artic roll, yoghurt or ice cream. The home has introduced the “Nutmeg Gold” menu planner, which gives a nutritional analysis of the menus provided. This is to make sure the residents have a balanced diet based on their preferences. On two of the units the mealtime was a relaxed pleasant time with residents being supported in an unhurried manner. The residents on the nursing unit need a lot of support and assistance. At least eleven need help to eat their meals and two tables of three residents needed constant attention. This meant that residents were getting up and leaving the dining room to be brought back by staff who were trying to assist individuals eat their meal while it was hot. Three residents had to wait until others had finished their meal before being served and assisted to eat and drink. Two residents were being assisted by their relatives who regularly visit at meal times. The four staff followed good practice by supporting one person at a time while prompting others, however there were more people who needed help that staff available to undertake this role. This was discussed with the manager who agreed that other staff could be brought to help on this unit at mealtimes. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedures are clear and easily accessed. This helps people to feel confident that their views are listened to and acted upon. Robust arrangements for Safeguarding Adults help to protect people 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, Service User Guide and is displayed in the home. Relatives said they would “go to the manager”, “tell the staff” if they had a concern. They also said that any concern was always “seen to straight away”. There has been one complaint since the last inspection, which has been resolved at home level. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 19 There are procedures in place to safeguard the people living in the home. The staff have received training and know when to involve external agencies. The new staff will compete their training via Future Strategies in June 2007. There have been three referrals since the last inspection. All have been satisfactorily resolved. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, warm, well maintained and suitably decorated so that the residents have a homely and comfortable place to live. 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, a small conservatory, and bathing and toilet facilities. All have access to nicely planted gardens and patio areas. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 21 Since the last inspection fireplaces have been fitted in the lounge areas. A partition is being erected in the large dining room in the nursing unit. This will let relatives join residents’ for a meal and have some private time together. A redecoration programme has started with doors being decorated and some signage being put so that people can find their way around the units. The carpet in the smoking lounge has several burn marks and the lounge chairs especially in the nursing unit are showing signs of wear and tear. Some have split cushions and chair arms are very marked with constant use. None of the bedrooms have an en suite facility. There are suitable toilets and specialist bathrooms and showers close to all resident areas. All areas of the home were clean and tidy with no odours. The laundry facilities are small and it is not possible to have a soiled and clean area. There is sufficient equipment to deal with the laundering of all clothes. There are infection control policies and procedures in the home. All staff followed the procedures and confirmed that they had completed infection control training. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current staffing levels is sufficient to meet the residents’ needs. A detailed training programme is in place to ensure staff have the competence to care for the residents needs. The residents are kept safe and supported by comprehensive recruitment procedures to prevent unsuitable people from working in the home. EVIDENCE: Each unit in the home is 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. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 23 The nursing unit has 3 carers and a qualified registered mental nurse during the day. Overnight there is I qualified nurse and 3 carers. There are sufficient ancillary staff employed over a seven-day period. These include, laundry, catering, administration, maintenance and an activity organiser. The levels of dependency on the nursing unit are high with at least ten residents needing two staff to assist them with all of their care needs. This was especially noticeable at meal times. Residents had to wait in turn for lunch, staff were not able to spend time assisting individuals as other residents needed prompting to eat or needed direction to come back and eat their meal. Relatives said that the “staff are good”, they are always busy” and “they could do with more staff at meal times”. The staffing levels at peak times were discussed at the time of inspection and the manager agreed to deploy more staff to this unit particularly at lunch times. The home continues with NVQ level two training with 95 holding the qualification. Six staff files showed that the recruitment procedures are followed. All contained evidence of completed application forms, interview records, two written references, terms and conditions of employment and induction records. Criminal Record Bureau and POVA First checks are carried out and these records are held securely. Personal Identification Numbers (P.I.N.) numbers of qualified nurses are checked with the Nursing and Midwifery Council to make sure nurses are registered. Each member of staff has a separate training and development file. Evidence from the files and from discussion with staff confirmed that they have received training in moving and assisting, first aid, food hygiene, infection control and fire safety. Other training includes, safe handling of medicines, protection of vulnerable adults, care planning, “Yesterday, Today and Tomorrow” which includes dealing with challenging behaviours. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 24 The deputy manager is completing the Registered Managers Award and two nurses are completing a degree in dementia care. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an experienced and proficient manager who provides leadership. This ensures the home is run in the best interests of people using the service. Clear systems for consultation and quality monitoring make sure that the views of residents are sought and acted upon. Residents personal accounts are well managed to ensure their best interests are protected. The health, safety and welfare of residents are being protected as far as reasonably possible. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 26 EVIDENCE: The registered manager is experienced and competent to manage the home. She continues to update her knowledge to continually improve the service for the people who live in the home. Since the last inspection she has been bases in the home and the direct leadership and supervision has improved the record keeping especially in regard to care plan and medication recording. The manager holds regular staff meetings for all grades of staff with records kept. Although there is evidence that resident and relative meetings are organised they are poorly attended. Relatives said that if they had any problem they would be able to see the manager straight away and “things would be sorted”. The manager also holds weekly surgery’s where people can meet and discuss any issues on an individual basis. The Company’s’ quality assurance system includes internal monitoring of complaints, maintenance, catering and domestic services. Storage and administration of medication is audited on a regular basis. Care plans are also internally audited with a number being randomly selected each month. The regional manager carries out regular audits and reports with actions and outcomes are available in the home. The home has clear systems in place to make sure residents personal money is kept safe. The company carried out a full audit of the finances at the beginning of the year. Receipts are available for all transactions, which could be cross-referenced to the records. Reconciliation of the accounts takes place weekly and residents are encouraged to have their own bank accounts. It is not possible to audit individual monies as all money is held in a non-interest bearing account. central 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. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 27 A fire risk assessment is available and up to date. Water temperatures are recorded to ensure temperatures of 44 C is not exceeded. Accidents are clearly recorded and the manager completes monthly accident analysis to examine and track any trends. All internal maintenance checks are dated and signed. External service contracts were available and up to date. Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 28 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 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 3 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 X 3 X 3 X X 3 Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 1 Standard OP20 OP20 Regulation 16,23 16,23 Requirement The registered persons must ensure that the carpet in the smoking room is replaced. The registered persons must ensure that the worn lounge chairs in the nursing unit are replaced as part of the refurbishment programme. Timescale for action 01/09/07 01/11/07 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 Refer to Standard OP27 Good Practice Recommendations The dependency levels should be constantly reviewed to make sure that sufficient staff are available on the nursing unit at peak times. It is recommended that the sink in the treatment room be replaced with a stainless-steel unit with a draining facility 2 OP9 Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elizabeth Fleming Nursing Home DS0000018191.V335985.R02.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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