Inspection on 21/07/06 for Falstone Court Nursing Home

This inspection was carried out on 21st July 2006.

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.

Other inspections for this house

Falstone Court Nursing Home 20/07/09

Falstone Court Nursing Home 24/08/07

Falstone Court Nursing Home 02/02/06

Falstone Court Nursing Home 01/09/05

Falstone Court Nursing Home 10/02/05

Falstone Court Nursing Home 07/07/04

Falstone Court Nursing Home 13/02/04

Similar services:

Eastwood

Farmborough Court

Connolly House

Craghall Residential Home

Elaine House

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

CARE HOMES FOR OLDER PEOPLE Falstone Court Nursing Home Rocklodge Road Roker Sunderland SR6 9NQ Lead Inspector Sam Doku Key Unannounced Inspection 10:00 21 and 26th July 2006 st 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 Falstone Court Nursing Home DS0000018192.V302907.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. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Falstone Court Nursing Home Address Rocklodge Road Roker Sunderland SR6 9NQ 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) 0191 549 6699 0191 549 7799 Apta Healthcare (UK) Ltd Jill Mullea Care Home 41 Category(ies) of Dementia - over 65 years of age (41) registration, with number of places Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 Brief Description of the Service: Falstone Court Nursing Home provides accommodation and nursing care for 41 older people with a dementia type illness. Falstone Court opened as a purpose built home in 1995 and is next door to a sister home Falstone Manor. A General Manager oversees both homes and is based at Falstone Manor, as are personnel records and financial information. The Home has two floors with communal rooms available on both floors. All areas within the Home are accessible to people with mobility difficulties. Ensuite toilet facilities are available in the bedrooms and toilets and bathrooms are available throughout the Home. The home is on the sea front and can easily be seen when driving along the sea front main road towards the city centre. A car park is provided and the home is accessible to wheelchair users. The scale of charges for the home is £379.00 per week. Other charges relating to continuing healthcare and self-funding are available in the home. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over two days and the second day of the inspection involved two inspectors. The main inspection activities took place on the 26 July 2006. Before the inspection a pre-inspection questionnaire was sent to the manager for completion. The information provided in the questionnaire has contributed to the inspection process. The home is well equipped with aids and adaptations suited to the client group’s age and lifestyle preferences. The home has plenty of space in all areas. This inspection process involved talking to service users, visitors, sitting in the lounge and observing staff interaction with the service users, discussions with the Unit Manager, the registered General Manager, and care staff, tour of the building, examination of health and safety records, staff records and service users’ personal file including care plans. Lunch was taken with some service users in both of the two dining rooms. The atmosphere in the home was calm and peaceful and service users and relatives were able to express their views freely to the inspectors. The care staff were very helpful and cooperative with the inspectors. What the service does well: The Unit Manager runs the home well with regular support from the General Manager. Visitors who were spoken with stated that their relatives receive a good standard of care. The role of the activities coordinator is highly valued and appreciated by the relatives and staff. Relatives spoke of better communications between staff and themselves in recent months. The management team is good at taking initiatives that enhances the care environment and the care regime in the home. The staff have been instrumental in improvements in the home which benefited the service users. These environmental initiatives have greatly improved the orientation and cognition amongst the service users. There is evidence that service users are less confused and agitated since those environmental adaptations were put in place. The Home has welcoming surroundings and a friendly atmosphere. All visitors to the home are made welcome and treated with courtesy and respect by the staff. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 6 There are good arrangements in place for ensuring the service users have regular contacts with the community. Regular bus trips to the places of interest are a common feature in the care regime in the home. The home carries out a quality audit questionnaires with relatives. The results of such survey are to be compiled in a report form and published. What has improved since the last inspection? What they could do better: The issue relating to the level of supervision and assistance for service users at meal times still remain an area where improvements could be made. The mealtime arrangements should be reviewed with the view to offering assistance to those who need it in a timely fashion. Although staff supervision is taking place in some cases, the frequency of the supervision needs to be reviewed to ensure that all staff receive adequate number of supervisions throughout the year. There were concerns expressed by a relative that the unit manager and other seniors/nurses seldom work on the first floor of the home. The General Manager should review the duty system to ensure that there is a visible presence of the senior staff, including the unit manager both floors. Care management assessments are unavailable in some cases although the home conducts their own assessment before admission is arranged. Also records of six-weekly case reviews are not available in some cases. The record of training is not easy to follow and should be re-structured to provide detailed record of training received by all staff. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 7 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. Falstone Court Nursing Home DS0000018192.V302907.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 Falstone Court Nursing Home DS0000018192.V302907.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides information to the general public, which contains details about the home and the services provide. This assists prospective service users and their relatives to gain useful information about the home. In most cases appropriate assessments are received from the social worker before admissions are arranged. This enables the home to determine the care needs of the person and formulate care plans to meet those needs, thus meeting the needs of the service users. The home actively encourages prospective service users or their relatives to visit the home, meet with staff and other service users before deciding on whether or not to choose to live at Falstone Court. This provides the opportunity for prospective service users to make informed choice about their choice of home. EVIDENCE: Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 10 The service user guide provides useful information about the home and the services provided. This is made available to all service users and their relatives and available for anyone making an enquiry. Relatives commented on the guide, which they found useful when they were seeking information about Falstone Court. In the large majority of cases the home had obtained social work assessments before admissions are arranged. The home also carries out their assessments of the individual in their own setting to make sure Falstone Court Care Home has the necessary skills and facilities to meet the needs of the prospective service user. These arrangements ensure that the social worker, the home, the prospective service user and the relatives are confident that the home is able to support and care for the person before they move in. However, in a few cases the social worker’s assessment report was not available to the home although the home did carry out their own assessment. Prospective service users and or their relatives have the opportunity to visit the home before admission is arranged. One service user who was spoken with commented positively on these arrangements by the home to allow her and her relatives to visit the home and for the opportunity to meet with other service users and staff. This was confirmed by a relative who was also involved in the pre-admission visit to the home. They all said they found the exercise helpful and said it made it easier for them to decide on the home as their preferred choice. It is however, acknowledged that because of the mental frailty of most of the service users, the opportunity to visit the home before admission had not always been appropriate. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made from evidence gathered both during and before the visit to this service. Care plans provide detailed action plan on meeting the needs of the service users. This ensures that staff carry out care tasks in a consistent manner for the benefit of the service users. However, the review sheets that accompany the care plans do not reflect the effectiveness of the care plans. Medication systems are safe and appropriate and service users receive appropriate medication thus promoting their health and welfare. Service users are treated with respect and dignity thus promoting their selfesteem and psychological wellbeing. EVIDENCE: The service users care plans set out their care needs and action plan for meeting these needs. Care plans are regularly reviewed thus ensuring that the current care needs of the service users are being addressed and changes made to those needs where necessary. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 12 However the monthly review notes did not specify how effective or ineffective the care plan had been. Care plans provide details about the mental and psychological care and how these were to be provided. The home maintains record of contacts with healthcare professionals, including GPs, psychiatrist, chiropody service, dentist, optician and other healthcare services. Entries in the report books provide evidence that the home continues to engage the services of community medical practitioners and other professionals in the provision of care and for general advice and support. This ensures that the service users rights to proper healthcare are being safeguarded by the home. Relatives and service users confirmed that the healthcare needs are met through the arrangements for them to have access to healthcare facilities. However, the unit manager expressed some concerns about the difficulties they experience in obtaining GPs for service users who come from outside the local area. This has sometimes led to delays in seeking appropriate medical attention for those affected by this situation. There are suitable arrangements in place for the storage and administration of medicines in the home. The drugs administration system was examined and there were no discrepancies. The proper drugs administrative system that is being implemented ensures that the health and welfare of the service users are promoted. Service users confirmed that the staff treat them with respect and dignity. This was also confirmed by relatives. Staff were noted to treat service users with respect in their contacts with them. Staff were observed to speak quietly and discreetly with service users when they were offering assistance with personal care thus promoting the person’s dignity. Falstone Court Nursing Home DS0000018192.V302907.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 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 this service. Staff continue to provide care regime that is based of good practice models which help to maintain the service users social, religious and recreational needs. Residents receive varied and nutritious meals but the arrangements at mealtimes did not provide adequate supervision and support for those who needed it. EVIDENCE: Service users files contain statements about their social, spiritual and recreational care needs. The “Residents Passport” file provides useful information to staff in understanding the service users thus enabling them to apply a holistic approach to the care they provide. The home continues to provide a wide range of activities for service users to choose from. The role of the activities co-ordinator has greatly enhanced the availability of meaningful activities available to the service users thus maintaining their interest and participation in community activities. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 14 Service users and relatives confirmed that no one is made to join in any organised activities if they did not wish to. This promotes the service users’ right to make choices for themselves. Service users continue to compliment the catering staff and quality of the meals provided in the home. Nutritional assessments have been carried out for those service users who require their diet intake to be monitored to ensure they receive adequate diet. The four weeks rotating menus provided evidence of varied and nutritious meals, including alternatives for the service to choose from. The service users were joined by the inspectors for lunch to observe the practices carried out by staff in serving meals, as highlighted at the last inspection. Whilst actions have been taken since the last inspection to provide more suitable support and attention to service users, there still seem to be problems relating to the way service users who require assistance are supported. These issues were discussed at length with the General Manager, Unit Manager. The Manager indicated that a further review of the procedures at mealtimes would be made to improve the arrangements, thus improving the level of assistance offered to those who need support during meal times. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 15 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 this service. The home has a clear and easy to understand complaints policy, which is accessible to the service users and relatives. This provides the opportunity for individuals or relatives to raise concerns and in so doing exercising their rights. Suitable arrangements are in place, which ensure that service users are protected from all forms of abuse and to protect their rights. EVIDENCE: The home has in place a satisfactory policy and procedural guidance on abuse and staff are aware of how to use the ‘Whistle Blowing’ policy should this become necessary. The Service User Guide and Statement of Purpose have summaries of the complaints procedure. This provides the opportunity for service users, relatives and the general public to complain or raise concerns if they wish. Service users and relatives confirmed that any concerns or complaints they may have would be treated seriously with the view to safeguarding the welfare of the service users. Staff have received training in vulnerable adults protection procedures. The staff showed good understanding of the vulnerable adults protection procedures and awareness of the need to protect service users from all forms of abuse. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 16 In discussions with relatives, it was obvious that any concerns raised were appropriately dealt with under the home’s complaints procedure, thus providing further confidence amongst service users and relatives that all concerns are taken seriously and appropriately addressed. The relatives confirmed that they have confidence in the complaints system and feel that any concerns would be appropriately dealt with by the home. One relative raised a number of issues with the inspector relating to the care her father receives. These individual care issues were raised with the unit manager and the general manager and the inspectors were assured that the home would engage in a dialogue with the person raising the concerns and to formulate care plans that would address these issues. This is a welcome approach that would benefit the service user. Falstone Court Nursing Home DS0000018192.V302907.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 25, 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides accommodation of a good standard. It is a safe, clean and comfortable environment, and promotes the service users’ orientation, privacy, independence and self-esteem. EVIDENCE: Falstone Court is a home designed to accommodate older people, some of whom may have orientation and mobility problems. Access into and within the home is good and meets the needs of those service users who have mobility difficulties or have use of walking aids or wheelchairs. The home is also designed to allow service users to circulate freely within the home and in the enclosed inside and outside gardens. There are specialist bathing facilities to promote independent use by those who are capable of doing so. All the bedrooms and toilets have suitable locks on the doors. There are prominent signs on bedroom, toilet and bathroom doors to Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 18 assist with orientation in the home. The internal garden has been designed in a way that provides calm and peaceful environment for the service users. These initiatives provide the opportunity for service users to remain independent and to enjoy good levels of privacy, peace and tranquillity. Window restrictors have been fixed to all windows and all radiators have suitable coverings, which ensures security and safety for the service users. Checks of hot water at randomly selected bathrooms confirmed that hot water did not exceed 43°c. thus protecting the service from accidental injuries. The lighting in some parts of the home is very poor and action must be taken to ensure that the lux levels in all parts of the meet the recommended standards for people who may have reduced visual capacity. During the time of the inspection a number of bedroom doors were noticed to be wedged-opened. This compromises the fire safety procedures in the home and the practice must ceased so as to protect the welfare of the service users. The home has written policies and procedures relating to safe handling of hazardous materials for staff to follow. The general manager indicated that staff have had training in health and safety, infection control and food hygiene. The home was noted to be clean and free from offensive odour. This enhances the self-esteem of the service users. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection. Falstone Court Nursing Home DS0000018192.V302907.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 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 area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides sufficient staffing complement, which meet the needs of the service users. However, there had been a number of instances in recent weeks where the required staffing levels have not maintained. This compromises the care and welfare of the service users. Suitable arrangements for staff training and supervision are in place, which ensures that staff are reasonably equipped to provide good quality service that benefits the service users. However, training and supervision would need to be reviewed to ensure that standards are met. EVIDENCE: On the whole, staffing numbers were found to be sufficient to meet the needs of the service users. The unit manager confirmed that the required staffing levels have consistently been maintained to ensure that the care needs of the service users are met. However, he acknowledged that in the past two weeks prior to the inspection, there had been reduced staffing levels due to sickness and holiday commitments. Staff indicated that during such times of reduced staffing levels, their time is often spent carrying out physical tasks and not having sufficient time to engage in therapeutic activities with service users. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 20 This negates the good work by the home in promoting good therapeutic practices in the home. The company’s employment policies are generally being adhered to by the general manager. The files of the most recently appointed staff members were examined. Appropriate references have been obtained and the necessary checks have been conducted, including CRB enhanced checks. However, in one case the previous employer’s reference come from a private address and not from the employer directly. The person’s second reference was from a work colleague but this was not signed or dated. Proper recruitment policies must be followed to ensure that the safety and welfare of the service uses are protected at all times. Overseas nurses have had all the necessary checks done and appropriate work permits have been obtained for them. According to information provided by the general manager through the preinspection questionnaire, only 9 of care staff have NVQ Level 2 or above qualification. The information also indicates that only one staff have current first aid certificate. It was difficult for the inspectors to carry out staff training audit as there was no centralised training list showing which training staff have received. The training issues must be addressed to ensure that the staff have the training necessary to ensure that the service users are cared for by competent staff. Falstone Court Nursing Home DS0000018192.V302907.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The manager runs the home for the benefit of the service users. This has created a pleasant care environment for the service users. However, the manager needs to address the concerns of a relative regarding the lack of his presence and that of other senior staff on the first floor. The system for managing the service users monies is good and protects them from financial abuse. The detailed organisational policies and procedures on health safety and welfare are adhered to by the staff, which protects the welfare of the service users. Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 22 EVIDENCE: The general manager has long experience of working in a care settings and has had good management experience in care homes. She has acquired the registered managers award. This training has further enhanced her skills for the benefit of the service and the service users. The day-to-day running of the home is by the unit manager who has good nursing and management experience. Staff described both the unit manager and the general manager as efficient and indicated that they run the service for the benefit of the service users and have positive relations with the staff. Similar comments were also made by some of the relatives. However, it was felt that the unit manager could be a bit more visible on the first floor as he spends most of his time on duty on the ground floor. Such practice creates the impression of preferential treatment for the service users on the ground floor. There are arrangements in place for staff to receive regular supervision from the manager. Staff confirmed that individual supervision arrangements are taking place but this is not at the frequency to meet the national minimum standard. The unit manager and the general manager both acknowledge that the frequency of staff supervision need to be increased to ensure that staff are adequately supported to undertake their duties. Staff who have had supervision confirmed that this has enhanced their skills and confidence and enable them to provide good quality care for the service users in their care. A record is maintained for those service users for whom the home handles their personal allowances. The details indicate that the service users monies are safe and managed well, thus preventing any possible financial abuse. The general manager conducts what she describes as Manager’s Surgery. This takes place once a month in the home. This process involves making herself available to relatives and service users to discuss any issues relating to the home and the service users. She indicated that this has been useful exercise in helping to review the service and to examine aspects of the care regime that is brought to her attention. The home has detailed Health and Safety policies. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). The manager stated that staff have had training in food hygiene, fire precaution and moving and handling. Such training ensures the health and safety of the service users and the staff. All portable appliances have been tested. A record is maintained of monthly water temperature tests in the home. There is evidence of regular servicing of Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 23 fire equipment, gas and electrical appliances being carried out by the Company. All the servicing records that were examined were up to date. These included fire fighting equipments, servicing of hoists, lift servicing, water treatment, electrical installation and gas servicing. Up to date servicing and maintenance of these services and equipments ensure a safe environment for the service users and the staff who work there. Falstone Court Nursing Home DS0000018192.V302907.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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 18 X 3 3 X X X X 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 2 Falstone Court Nursing Home DS0000018192.V302907.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 OP25 Regulation 23(2)(p) Requirement The Lux levels in some parts of the building must be re-assessed to ensure there is adequate lighting for people who may have visual problems. The required staffing levels must be maintained at all times. The home must follow proper recruitment procedures and obtain appropriate references for applicants. Statutory training must be provided for all the staff to ensure that they are adequately trained for their roles as care assistants. The practice of keeping bedroom doors wedged-opened compromises the fire safety in the home. This practice must cease. Timescale for action 30/10/06 2 3 OP27 OP29 18(1)(a) 19(1)(b) 26/07/06 30/08/06 4 OP30 18(1)(c)(i ) 01/12/06 5 OP38 23(4)(a) 26/07/06 Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 26 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 OP15 Good Practice Recommendations The level of supervision and assistance by staff for residents at mealtimes should be further reviewed to ensure that all residents are appropriately supported, and allow a more relaxing environment for all residents in the dining room. Staff training records should be organised in a way that allows the manager to monitor each staff member’s progress and identify where extra or refresher training is needed. The frequency of staff supervision should be increased to ensure each staff member receives adequate supervision throughout the year. 2 OP30 3 OP36 Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Falstone Court Nursing Home DS0000018192.V302907.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!