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Inspection on 21/08/07 for Eversley Nursing Home

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

This inspection was carried out on 21st August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Service users are properly assessed in the home to ensure that they are cared for appropriately. Health assessments are carried out routinely and there is good liaison with community health professionals to ensure a good service is provided. Complaints are dealt with appropriately and staff are very aware of the need to safeguard service users from abuse. All have received training and understand the procedures. Service users speak highly of the staff and say they will do anything for you. They felt listened to and could have a say in how things were done. They felt comfortable in the home. Relatives on the whole were quite comfortable in the home and felt their relative was treated individually. They felt staff were polite and pleasant towards them. The home is providing good training for staff especially on the topics of dementia and the protection of people from abuse. They also have encouraged a high proportion of staff to study for a national care qualification. Staff are well supervised with a system for regular one to one meetings and general staff meetings in place. Quality assurance systems are very good and help the home to be critical of itself. They have regular audits of themselves and can see where action needs to be taken.

What has improved since the last inspection?

Routines have become more flexible with service users having more choice about bedtimes and getting up. There has been considerable building work in the home with an extension built to increase the communal space, a safe garden created and decoration in several parts of the home brightening it up. New carpets have been laid and signs have been put on the doors to help service users find their way around, especially important for those with dementia. The building is much lighter and more attractive. There was no intrusive smell in the home. The menus have improved with a choice provided and posted on the notice board for everyone to see. Recruitment practices are tighter with all checks carried out before the new staff can start work.

What the care home could do better:

There must be better systems in place to ensure that medication is administered properly and that residents receive the medication prescribed for them. Some errors spotted during the site visit on 21st August were so concerning that the manager was asked to deal with the problem immediately. Action was taken but a full review of how medication is ordered and administered needs to be carried out. Care plans need to include information about the social care needs of the service users and what staff should be doing to ensure the best quality of life. More activities, outings and individual wishes should be considered to occupy service users both able and frail. The bathrooms in the home are in need of renovation. One adapted bathroom is satisfactory with a hoist to assist the residents but a shower room is shabby and used for storage whilst another is not used because there are no hoists. The way staff are first trained (induction training) should be better recorded to show that they understand the ways they are expected to work for the benefit of the service users.

CARE HOMES FOR OLDER PEOPLE Eversley Nursing Home 95-96 North Denes Road Gt Yarmouth Norfolk NR30 4LW Lead Inspector Mrs Dorothy Binns Unannounced Inspection 21st August 2007 10:00 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 Eversley Nursing Home DS0000015636.V349252.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. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eversley Nursing Home Address 95-96 North Denes Road Gt Yarmouth Norfolk NR30 4LW 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) 01493 854086 01493 857007 Country Retirement and Nursing Homes Limited Mrs Lynne Gilham Care Home 18 Category(ies) of Dementia (18), Old age, not falling within any registration, with number other category (18), Physical disability (4) of places Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. To accommodate one (1) service user with Physical Disabilities under 65 years of age, who is named with the Commission, for regular respite care. To accommodate up to eighteen (18) Older People. The total number of service users not to exceed eighteen (18). To accommodate up to 4 service users with a physical disability who may be under the age of 65. 23rd August 2006 Date of last inspection Brief Description of the Service: Eversley Nursing Home is situated in the town of Great Yarmouth within reach of local shops. It is a three-storey building with access to the 16 single and 1 shared room by a shaft lift. The communal areas consist of two lounges and two dining rooms with a separate small quiet room. The home has a patio area with shrubs and flower beds and a small space for parking. Eversley is a registered care home that provides nursing care for 18 older people and is owned by Country Retirement and Nursing Homes Limited. In March 2007 the registered person applied to change the registration to accommodate people with dementia who needed nursing care and this was granted. Currently the home accommodates eleven people with dementia and five older people who are physically frail. The charges for the home are £517 per week. Residents are expected to pay extra for chiropody and hairdressing. The inspection report for the home was displayed on the home’s notice board available for service users or visitors to read. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection of the Home and lasted six and a half hours. Discussions took place with the new manager and the provider about how the home was progressing and records and policies were examined. Three staff were interviewed in private and three service users were seen in their rooms. A relative was also interviewed. Observations were made throughout the day in the lounges and dining room and the building was inspected. In addition, the Commission asked the home to complete an Annual Quality Assurance Assessment, (AQAA), of their home which details what the home is doing and where they want to improve. Information received since the last inspection on the Commission’s own record has also been taken into account and mentioned in this report where appropriate. In addition a survey form was sent out to a sample of service users and relatives for their views about the home. Five service users and three relatives returned the form and their views have been incorporated into the report. Following a difficult period last year the home appointed a new registered manager who worked hard to restore standards in the home. She has now been promoted within the organisation and another new manager has just been appointed and is not yet registered. A change of manager is undoubtedly unsettling for the service users but both service users and staff had taken the change well perhaps because the care and nursing staff had stayed the same and the previous manager has been in attendance at least one day a week. Overall standards have improved in this home and the building has been renovated. The service users were very satisfied with their care. One major problem was identified during the inspection regarding medication which needed immediate action. Had it not been for this serious flaw, the home would have been judged as a good resource. As it was, only an adequate rating could be given though there are many good things about the home. The manager also impressed with her commitment to see through the necessary changes and to her responsibilities to the service users. What the service does well: Service users are properly assessed in the home to ensure that they are cared for appropriately. Health assessments are carried out routinely and there is good liaison with community health professionals to ensure a good service is provided. Complaints are dealt with appropriately and staff are very aware of the need to safeguard service users from abuse. All have received training and understand the procedures. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 6 Service users speak highly of the staff and say they will do anything for you. They felt listened to and could have a say in how things were done. They felt comfortable in the home. Relatives on the whole were quite comfortable in the home and felt their relative was treated individually. They felt staff were polite and pleasant towards them. The home is providing good training for staff especially on the topics of dementia and the protection of people from abuse. They also have encouraged a high proportion of staff to study for a national care qualification. Staff are well supervised with a system for regular one to one meetings and general staff meetings in place. Quality assurance systems are very good and help the home to be critical of itself. They have regular audits of themselves and can see where action needs to be taken. What has improved since the last inspection? Routines have become more flexible with service users having more choice about bedtimes and getting up. There has been considerable building work in the home with an extension built to increase the communal space, a safe garden created and decoration in several parts of the home brightening it up. New carpets have been laid and signs have been put on the doors to help service users find their way around, especially important for those with dementia. The building is much lighter and more attractive. There was no intrusive smell in the home. The menus have improved with a choice provided and posted on the notice board for everyone to see. Recruitment practices are tighter with all checks carried out before the new staff can start work. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 7 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. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users do have an assessment of their needs before coming into the home to make sure the home can take care of them. EVIDENCE: All service users have full assessments by outside agencies before coming into the home and each had a brief summary of assessment on their care files. This covered the main areas of physical care including mobility, personal hygiene and mental state and what skills the service users had in those areas. Assessments for risks of falling or pressure sores were also in evidence. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 10 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): 12,13,14 and15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service users’ personal care needs are set out in an individual plan though these could be fuller especially with regard to social care needs. The management have already identified this as an area for improvement. There is a good emphasis on the health care needs of the service users and appropriate liaison with community health care professionals. The way medication is ordered and organised does not give enough protection to service users and the home was asked to rectify the situation immediately. A full review of the medication systems has been required. Service users feel treated with respect and feel they have a say in how things are done. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three care plans were examined and all had an assessment which gave details of various aspects of the service user’s health and what their needs were. A risk assessment for pressure sores was in each file as was a falls assessments and nutritional assessment. One care plan was very detailed giving good instructions to staff so they knew what assistance was required. Others were not so fully formed and none had any mention of social aspects. However the new manager is bringing in new record keeping which will collect information about the life story of the service users. Relatives and staff will work together on ensuring staff understand the life that the service users used to lead and what things were important to them. An example of the this format was seen. This is a progressive move and will encompass more than just physical health. Staff confirmed that they were key workers to particular service users. Daily progress notes are written to keep all staff up to date and to ensure that appropriate actions are taken. Fluid charts are also maintained where appropriate. The files of the service users showed a good emphasis on maintaining the physical health of the service users. All had a thorough assessment on falls, nutrition, pressure sores and other health information. The manager reported that there are currently no service users with pressure sores though one who is susceptible is protected with an air mattress. One person is on oxygen. The files showed information on bloods being taken, the optician visiting, weight being monitored and liaison with doctors and social workers. The manager confirmed that district nurses also came into the home and they linked up with the continence advisor and the primary care trust. One relative was very pleased with the physical care offered to her husband. Another in the survey said the staff “manage the physical conditions well, encouraging mobility when he’s up to it”. Two service users seen confirmed they had their feet done by the chiropodist and that staff looked after them properly. The way the home handles medication was checked at the site visit on 21st August as a requirement had been made at the last inspection for improvements in the way medication was stored and recorded. Drugs were seen correctly stored in a locked cupboard and controlled drugs were double locked. The system used is the pre packed blister packs made up by the pharmacist though there were some packets of loose tablets as well. Only the nurses administer medication in this home and the charts were correctly completed. The charts showed however that medication was not given to some residents because their tablets had run out and the home had not been able to obtain further supplies. The nurse reported that they had contacted the surgery without result. All the records were checked and three service users Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 12 had run out of drugs, the longest for 6 days. In addition the blister packs were checked against the records. Although the charts showed that all service users had received their medication (apart from where the they had run out of tablets), the packs had different amounts of medication in them and it was not clear why or which days the packs referred to. The controlled drugs book was seen and correctly showed two signatures and the balance of stock. Homely remedies were also recorded with dates and who had received them. One service user did administer some of her own medication though she said the staff checked from time to time that she was administering correctly. She felt she could deal with all her medication but this was not offered. The nurse said that the service user had indicated that she preferred the home to look after her medication. All three service users spoken to on 21st August were very complimentary about the staff and felt they were treated well and staff tried hard to make them comfortable and happy. “I can’t fault them” said one. Another said that “staff look after you properly”. They felt that they could come to their rooms when they wanted and could enjoy some privacy and that staff were polite and respectful. Of the five replies from service users to the survey, all said that staff listen and act on what they said. One relative in the survey said that “staff are warm and friendly and treat my mother as an individual”. Another said “they were approachable and endlessly patient”. One area of privacy which does need improvement is in the provision of locks on the toilets and bathrooms – see next section. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 13 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 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle in the home satisfying and flexible seeing their visitors when they want and making some decisions themselves. They would like more stimulation and particular attention should be given to those who have dementia. Whilst offered a varied and nutritious diet and special diets if required some improvements to the quality of the food could be made. EVIDENCE: Routines in the home seem to vary depending on the individual with the three service users seen on August 21st giving different times for bed and getting up. One person had noticed that service users were not being put to bed so early following a mention in the last inspection report and this included some who could not speak up for themselves. Two service users said they spend a lot of time in their room and another that she always comes up to her room in the afternoon. One said “I can choose to be where I like”. Baths seemed to be fairly routinely given with one a week though one person said she’d like two. Bathing facilities are not inviting which may be a deterrent. One person said that although she only had one bath a week it was quite an occasion with bubbles and massage. Comments from service users about the staff were very positive indicating that routines were not inflexible and that staff tried to Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 14 accommodate them. “I feel very lucky to be in this home”, “Staff are ever so nice” and “I get on famously with staff” were some of the comments. One relative thought the routines were “fine” and she “couldn’t say anything against the home”. An activities person was seen in the building when the inspector arrived on 21st August and he was doing a card game with some service users. The service users said he came every week. One person confirmed that a “chapel person comes”. An activities folder showed that in the past there have been clothes shows, parties and musical entertainment. In the survey 40 thought there were “always” activities, 40 “usually” and 20 “ sometimes”. There was no mention of social interests in the existing care plans and there was little evidence of individual activities being offered to service users or their involvement in household tasks or being taken for a walk. The manager is introducing new life story books which will be completed with the help of relatives and these will have much more information about what is or was important to the individual service user and what social interests they like, giving ideas to staff about how to assist those not able to ask for themselves. The new manager was aware of the need to introduce more social stimulation and some service users themselves may help her if consulted. One service user told the inspector about liking quizzes. Two relatives were seen at the visit on 21st August and they confirmed that they could visit when they liked and take out their relatives as they chose. They saw them privately in their rooms and were offered a cup of tea. They thought they were kept informed about their relative’s progress by the staff especially important in one case where the relative in the home was unable to speak up for himself. All service users are encouraged to look after their own finances or to have a relative to help them. The home does not administer any service users’ finances. Service users are also encouraged to bring their own possessions into the home to make their rooms homely. The philosophy of the home is to encourage service users to exercise control over their own lives wherever possible though some service users are quite frail and rely on staff. One relative in the survey said “My (relative’s) life is not the one he would choose but the care home do their best within his limitations both physical and mental”. The home’s quality audit is based on taking into account the views of the service users and how they see the service. Menus were displayed on the wall of the dining room showing choices at dinner and tea. The manager confirmed that a four week rotating menu had just been introduced. A tick list was seen showing that the service users had been asked for their choices for the day. Three service users visited had some reservations about the food. One said the food was “generally good from the main cook” and “there was no choice but they would find you an alternative”. Another said there was “one good cook and I eat all her meals” and “if I say I want something different they will make it”. Another service user said the food was Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 15 nice even though her diet was restricted. All three had some meals in their rooms. One complained of food being cold and having to send food back. Service users said fresh fruit was available and in the kitchen there was evidence of fresh fruit and vegetables. In the survey which five service users responded to 80 said they “usually” liked the meals. The home does cater for special diets and these were shown in the care plans. One file seen showed that a service user had difficulty in swallowing so a soft diet was agreed. A nutritional assessment was in place showing what foods were good for the service user. There were no records in the kitchen to remind the cook of what was required but the manager said that the cook knew the service users and their needs well. Some service users were being fitted with plastic aprons to wear when having lunch. They were asked first if they wanted them but these looked institutional. Service users were seen being asked for their choice at the lunchtime meal and offered an alternative if they did not like the menu. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is a simple and accessible complaints procedure which service users and their relatives can use and they feel they can speak up and will be listened to. Service users are now better protected from abuse with stricter procedures and better training for staff. EVIDENCE: The complaints procedure was seen in the service users guide and the address of the Commission is included. Service users spoken to felt they would be able to raise concerns with the staff and that it would be dealt with. The manager produced a record of complaints made, with details of any investigation, letters written and actions taken. This demonstrated that concerns were listened to and looked into. No complaints have been received at the Commission during the last twelve months. An adult abuse policy was seen which related how the home would deal with allegations of abuse. The procedure linked in to local multi agency procedures informing the Adult Protection Unit and the Commission. When asked, all staff seen at the visit on 21st August said they had received training and were aware of the need to protect service users. The staff records sampled showed that staff had received training and the manager confirmed that all staff have been trained. No referrals have had to be made to the Adult Protection Unit in the last twelve months.. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home has undergone quite extensive renovations in the last twelve months and is looking attractive for the service users. Equipment is provided to assist service users more easily and signage for those with dementia is much improved. The main renovation still required is in the bathroom facilities. EVIDENCE: A tour was made round much of the premises and the improvements to the building were in evidence. The extension is completed providing more communal space for the service users with a bigger lounge and dining area leading to a pleasant patio area with secured gates. A ramp is provided to make movement easier. Plants have just been planted and need time to flourish but eventually this will be a very pleasant area. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 18 The existing lounge has also been repainted and carpeted, the corridors improved and some toilets repainted. Service users were seen remaining in their chairs in the lounge at mealtimes instead of using the dining areas with small tables placed in front of them to eat. The service users did not mind this though a change of scenery and some exercise moving rooms may have suited them better. The home has one bathroom with a hoist on the first floor and an adapted shower room with chair on the ground floor. This is next to the sluice area so did have a smell and was shabby. Both of these facilities were on the call bell system but had no locks on the doors. One other bathroom is not in use and there is no bathroom on the top floor. There are separate WCs in the home though none had locks. The home has nine bedrooms with en suite facilities. Many rooms were seen to have commodes. Both call bell and lift were tested and worked satisfactorily. Apart from the sluice there were no offensive smells in the home. The signage in the home is improved with all service users having their picture and the number on their room door. Toilets are also signposted. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users can be confident that staff are properly vetted before they start work and that training opportunities are ensuring that staff are competent to do their jobs. The home has a good proportion of care staff who have a national care qualification. Currently the service users’ needs are met by the numbers and skill mix of staff though social care still needs more attention. EVIDENCE: At the site visit of 21st August the staff rota for the week of the inspection was examined and checked against the number of staff on duty. One nurse is on duty at all times (three nurses covering a 24 hour period) and three carers are on duty till 3 pm and two on duty after that till 9pm. One carer was on duty with a nurse during the night. Most staff do one long shift a week (8am till 9pm) which staff said they did not mind but which is tiring. Catering and domestic staff are available over and above the care staff and the manager also does office hours. Both relatives and the service users thought the staff were very good and gave a good response when they were needed. One service user said they were rushed and gave an example when there was a staff shortage. For 16 service users currently accommodated the rota was judged to provide sufficient staff except that in a previous section of this report, more social care should be provided. The home’s own quality audit Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 20 confirms that the needs of the service users are met by the numbers and skill mix of staff. The home’s own quality audit reports that 9 out of 11 staff have an NVQ2 qualification and that the remaining two are working towards it. Two staff interviewed said they had their qualification. This more than exceeds the standard of 50 trained by 2007. Three staff files were examined to check recruitment procedures. At the last inspection in 2006 recruitment procedures had not been rigorous enough and a requirement was made for improvement. Several of the staff come from Eastern Europe and their vetting starts in their home country. Translated references were in evidence from official bodies like hospitals where staff had worked or colleges where they had received their diplomas. Staff had also been checked for criminality and against the list of people who are not to work with vulnerable adults. Identity documents were on files as well as declarations of health and evidence of qualifications. The start date showed that staff had only started work after all the documentation was complete. Contracts were also seen. The staff files showed that induction training was being provided for staff and that questionnaires were being used to test staff. The common induction standards have been used since October 2006. On the staff training plan it showed that staff had received first aid, fire training and moving and handling training but the dates did not correspond to their start dates so it was not clear what they had covered in induction. One new staff interviewed confirmed she did have an introduction to the work and observed senior staff in their tasks. All staff have received dementia awareness training and validation techniques because of the homes recent change to accommodate service users with dementia. One staff confirmed that she was taking a longer course in dementia. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users live in a home that is run in their best interests and is improving in its practice. The manager is new but has the commitment to run the home well and has a hierarchy of supportive managers. The home also has a developed system for checking its own quality which helps it to see where improvements lie. The health and safety of service users and staff are also protected. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager has been promoted within the organisation and a new manager has been appointed. She had only been in post for two weeks at the time of the site visit on 21st August 07. She reported that she has an NVQ4 qualification in care and is undertaking her registered manager’s award. She intends to take some accredited dementia training. She has worked in the care sector for many years including dementia units. She is supported by a senior nurse overseeing the nursing care in the home and the area manager who was the registered manager of the home. Although not yet registered and an application will have to be made in due course, the manager conveyed a thorough understanding of her role and her intention to discharge her responsibilities fully. The home has well developed quality assurance system which is based on surveys of the views of service users and relatives, as well as on measuring themselves against the national minimum standards to see how they comply. An annual report is produced and the one for 2006/2007 was available. This shows a summary of the analysis and what is being done and is in an easy to read format. The home also has regular visits from the organisation’s directors and a report is made of the visit with a list of actions to be taken to improve things. The home also responds to CSCI reports and ensures that service users have access to inspectors. The home does not manage any of the service users’ monies and has a system in place where the home pays for certain items like hairdressing and invoices the relatives. Staff confirmed that they have opportunities to meet one to one with their manager on a regular basis to discuss aspects of their work and their training needs. One such meeting was planned for the day of the site visit on 21st August. The new manager showed a list on the wall of the supervision meetings she has planned. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 23 The health and safety of service users and staff are promoted by the home’s policies and commitment to training of staff. Policies were seen on health and safety including employers responsibilities, infection control, fire prevention and risk assessments. The sampled staff records showed that training was given on moving and handling, food hygiene and first aid and other topics on the induction programme. Risk assessments were seen on all the care records sampled and the accident record is appropriately kept. Gas and electrical installation certificates were seen dated during the last 12 months and the fire record showed that emergency lighting, extinguishers and drills were all up to date. A record was kept of water temperatures and the lift had been serviced recently. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 24 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 2 3 x 3 x x STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x N/a 3 x 3 Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13 (2) Requirement Timescale for action 30/09/07 2. OP9 13(4) 3. OP9 13(2) 4. OP12 16(2)(n) The registered person must make arrangements for the recording, handling and safekeeping of medicines received into the home. Previous timescale 31/12/06 The registered person must 28/08/07 ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. In this instance, service users did not receive their medication because of flaws in obtaining prescriptions. This was made an immediate requirement at the time of the visit. The registered person must 30/09/07 conduct a review of how the home handles medication and ensure that safe systems are in place. The registered person must 30/11/07 consult service users about a programme of activities arranged by the care home and provide facilities for recreation. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 26 5. OP21 12(4) The registered provider must make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of the service users. In this instance there are no locks on toilets and bathrooms. 30/11/07 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. 2. 3. 4. Refer to Standard OP15 OP15 OP21 OP30 Good Practice Recommendations It is recommended that the quality of the meals is reviewed. It is recommended that a list of special diets is kept in a record in the kitchen. It is recommended that the registered provider reviews the bathroom and toilet facilities. It is recommended that the induction training is better documented to show what topics are covered and how it is verified. Eversley Nursing Home DS0000015636.V349252.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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