Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 30/08/07 for Firbank House Nursing Home

Also see our care home review for Firbank House Nursing Home for more information

This inspection was carried out on 30th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

During this visit there was a relaxed and informal atmosphere, and people living in the home appeared settled and at home in their environment. People who were spoken to said they felt comfortable with the staff team and that they could approach them with any concerns. Staff were observed as they engaged in meaningful conversations with residents, and where appropriate, they offered support and reassurance in a sensitive and caring manner. One person living in the home said, " I like it here, I have a nice bedroom and the staff are very helpful". One visitor said she thought that the staff provided good support to the residents. She said that staff were warm and open, "You always feel the staff are open and welcome. Nothing is too much trouble if you have a query." There is a useful guide that provides people with useful information about the service and helps them to decide if the home is the right place for them, and can support them with their care needs. Encouragement is given to people to develop and maintain relationships with family and friends, and to participate in the local community. There was evidence during this visit that there are established relationships with a variety of community resources, and that the staff support people living in the home to access these social and leisure opportunities.

What has improved since the last inspection?

Care plans have been fully audited so that staff have clear information on how each resident wants to be supported. Systems are in place which help staff to monitor and evaluate the ongoing care needs of the residents living in the home. Recruitment processes and staff training had been prioritised, so that residents can be confident and satisfied that their interests and well being are being protected. The staff training programme now includes training in safeguarding adults, and staff have been nominated to attend a series of training sessions to ensure that they have the relevant knowledge base to protect residents from abuse. A programme of ongoing maintenance and renewal ensures that residents benefit from a pleasant and clean environment, and additional domestic hours meant that the home was kept clean and tidy.

What the care home could do better:

Residents and their families or representatives, should be provided with the opportunity to sign their care plans, to indicate that they have been fully involved in the care planning process where possible. There should be more consultation with residents, asking them about their interests and preferences about lifestyle. This will ensure that their social, cultural, religious and recreational interests are met. Some improvements were required in the auditing of medication procedures, and the manager had identified that this was needed and had instigated the process at the time of this inspection visit

CARE HOMES FOR OLDER PEOPLE Firbank House Nursing Home 24 Smallshaw Lane Ashton-under-Lyne Tameside OL6 8PN Lead Inspector Ann Connolly Unannounced Inspection 9th August 2007 12:00 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 Firbank House Nursing Home DS0000025433.V342068.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. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firbank House Nursing Home Address 24 Smallshaw Lane Ashton-under-Lyne Tameside OL6 8PN 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) 0161 343 1251 0161 343 1007 firbankhouse@aol.com Partnership Caring Limited Julie Richardson Care Home 42 Category(ies) of Dementia (20), Dementia - over 65 years of age registration, with number (20), Old age, not falling within any other of places category (42), Physical disability (22), Physical disability over 65 years of age (22) Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing: Code N, to service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Dementia: Code DE (maximum number of places: 20) Dementia over 65 years of age: Code DE(E) (maximum number of places: 20) Old, not falling within any other category: Code OP (maximum number of places: 42) Physical disability: Code PD (maximum number of places: 22) Physical disability over 65 years of age: PD(E) (maximum number of places: 22) No service user under 55 years of age can be admitted to the establishment. The maximum number of service users who can be accommodated is: 42 Two first level Registered Nurses to be on duty between 8 am - 5 pm. One first level Nurse to be on duty between 5 pm - 8 am. Manager’s hours to be supernumerary to 2 & 3 above. No more than 30 places can be used for nursing care. 2. 3. 4. 5. Date of last inspection 6th December 2006 Brief Description of the Service: Firbank House is situated near to Ashton-under-Lyne town centre. The home consists of two buildings, referred to as the main building and the annex. Nursing and personal care can be provided for up to 42 residents. The home is owned by Partnership Caring Limited, which is a private company, and is under the day-to-day control of a manager who is also a registered nurse. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 5 Fees for accommodation and care at the home range from £271.44 to £409.49 per week. Extra charges are made for sundry items such as toiletries and newspapers and services such as hairdressing and chiropody. Twenty-one service users are accommodated in each building with rooms being spread over two floors. There are a total of 36 single rooms and three double rooms, of which the majority have en-suite facilities. Seven communal rooms offer a variety of settings in which service users are able to receive visitors, socialise and participate in activities. The home is close to local shops and bus routes. There is ample parking for those who choose to travel to the home by car. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 30/08/07 at 12:00 noon, over a four and a half hour period. Before the visit to the home, the manager had sent information to the Commission about how the home was run. During the site visit a selection of records, care plans, policies and procedures were examined. Discussions took place with the manager, staff working in the home and the residents living there. Prior to the inspection, questionnaires were sent out to the people who live in the home, asking them to comment on how the home is run and managed, and for their views about how the staff supported them. A number of these were retuned and the comments have been included in this report. Several residents living in the home were spoken to during the visit, and discussions took place with them to find out what they thought about the home and what they felt about how the staff supported them. Since the last inspection visit, which took place on 6th December 2006, the Commission for Social Care Inspection has not received any complaints about this service. The home’s manager has received one complaint about the home. Procedures were followed and the complaint was appropriately investigated. What the service does well: During this visit there was a relaxed and informal atmosphere, and people living in the home appeared settled and at home in their environment. People who were spoken to said they felt comfortable with the staff team and that they could approach them with any concerns. Staff were observed as they engaged in meaningful conversations with residents, and where appropriate, they offered support and reassurance in a sensitive and caring manner. One person living in the home said, “ I like it here, I have a nice bedroom and the staff are very helpful”. One visitor said she thought that the staff provided good support to the residents. She said that staff were warm and open, “You always feel the staff are open and welcome. Nothing is too much trouble if you have a query.” There is a useful guide that provides people with useful information about the service and helps them to decide if the home is the right place for them, and can support them with their care needs. Encouragement is given to people to develop and maintain relationships with family and friends, and to participate in the local community. There was Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 7 evidence during this visit that there are established relationships with a variety of community resources, and that the staff support people living in the home to access these social and leisure opportunities. What has improved since the last inspection? 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 Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed prior to admission into the home and trial visits are arranged to help prospective residents make an informed choice about their future care arrangements EVIDENCE: A comprehensive admission policy was in place, which included information about opportunities for people to visit the home on a trial basis, stay for a meal and talk to existing residents and staff. Information provided by the manager before this visit in a self-assessment document, stated that all existing and prospective residents were provided with the statement of purpose and service user guide. These documents are useful in helping prospective residents to make an informed choice about their future care Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 11 arrangements. During this visit, it was noted that these documents were available in every bedroom. The care plans were examined and they contained assessments carried out by the care manager from the placing authority. In addition, an assessment of care needs was carried out by the manager of the home, and the information obtained was used to develop a detailed care plan for each resident. The preadmission assessment included personal details and information on personal care, past history, continence issues, mobility difficulties and medical history. Intermediate care is not provided at Firbank House. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provided staff with the information they need to meet and monitor the resident’s needs. Dignity and privacy is respected for residents at all times. EVIDENCE: Three care plans were examined during this visit. The information in the care plans provided information and details about each resident’s care needs. There was evidence that changes in care needs were promptly identified, and that where necessary appropriate referrals had been made to the medical profession. One resident had a recent history of falls. Staff had completed appropriate reports, and written records showed that the General Practitioner had been consulted. The process was monitored and recorded, and the outcome for this resident was a referral to the ‘falls’ clinic. There was evidence that all care plans had been fully audited and each plan was divided into sections, which made it easy for staff to use as a reference tool to monitor the health and well being of residents. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 13 A variety of risk assessments are completed by staff. This is to ensure that any risks that are taken by residents can be done in a safe way where possible. Records and discussion with residents showed that a variety of health workers visit the home to assist with residents’ care. These are people such as dentists, opticians and dieticians. Staff who were spoken to had a good understanding of the care planning process, and the importance of involving residents in planning their care. The manager recognised the importance of constantly monitoring the care plans to ensure that staff are provided with adequate up to date information about residents. It was evident from talking to some visitors that it was the policy to involve residents and their families in the review of care plans. There was no recorded evidence to indicate that this practice had taken place. It was recommended that care plans and reviews include the signatures of residents and their relatives or representatives where possible, to indicate and demonstrate their involvement in the process. Examination of residents’ medication administration records showed that medicines were generally administered satisfactorily. On the nursing unit it was found that medication stock levels balanced with the Medication Administration Records (MAR), and there were good recording systems in place to record the receipt and disposal of medication. The medication records contained a section on guidance for staff when administering medication. There were specimen signatures of all staff responsible for the administration of medication, so that any tracking of administration could be undertaken. However, on the residential unit, the records of medication being received into the home were not consistently recorded, and on some records it was not possible to carry out an audit trail. There were also occasions where hand written entries of medication had not been countersigned by a second member of staff to ensure accuracy in the detail. Both of these shortfalls had been identified in the last inspection visit. It was noted that the manager had identified some of these shortfalls prior to the inspection visit, and as a result she was in the process of tracking which staff were making the errors, and had planned staff meetings with them. There was also evidence in the diary that an audit of medication had been scheduled for this week. This provided evidence of a service that was committed to improving the systems in the home to ensure the health and well being of service users. Staff were observed engaging in meaningful conversations with residents, and at all times, communication appeared respectful. Residents spoke highly of staff. Some residents said that some staff “were better than others”. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 14 Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. Activities were offered, but these need to be expanded to ensure that the social, cultural and recreational needs of residents are met. Residents were encouraged to maintain contact with family and friends. Meals served to residents were of a good quality providing a nutritionally balanced meal. EVIDENCE: This home does not have an activities organiser, and it is left to care staff to try and organise the activity programme in the home. A keep fit session is offered every week, and all residents who were spoken to spoke highly of this, and said how much they enjoyed it. One resident said, “ We don’t do much, but on a Monday we do aerobics and everyone likes that”. One of the comments in the survey forms, which are completed by residents and their families, said that there were ‘definitely not enough activities available’. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 16 There was evidence that the activity programme was under review and being developed. There was photographic evidence of trips out, and information provided by the manager indicated that the staff tried to consult with residents to ensure that activities were appropriate for those residents living in the home. There needs to be a pro-active approach in consulting with residents about their interests so that their social, cultural, religious and recreational interest are met. During this visit a number of residents received visits from their friends and relatives. Most people spoken to said they felt that staff made them feel welcome. One relative said, “ I always feel that staff are open and welcoming. Nothing is too much trouble if you have a query for them”. There was information on advocacy services displayed on notice boards throughout the home. Information provided by the manager prior to the inspection stated that all residents and their families were offered the opportunity to use advocacy services at any time and in particular for review of care needs and placement. The meal served during the visit appeared wholesome and was well presented. Residents were offered a choice of menu. There were mixed comments from residents about the quality of the food served, but most indicated they either ‘usually’ or ‘sometimes’ liked the meals. The catering staff confirmed that when residents did not like any choices on the menu, every effort would be made to offer a suitable alternative. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 17 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. Policies and procedures are in place to ensure that residents are protected, and systems are there to support residents to make their concerns known. EVIDENCE: There is a comprehensive complaints policy in place. This is located in reception areas and in the statement of purpose and service user guide. Responses from surveys sent out to residents and their families indicated that on the whole, people knew how to voice their concerns and complaints. It was evident from some of the responses that families felt confident in raising their concerns. One family member said that she felt confident and able to go to see the manager or staff with any issues of concern. There was only one person who indicated that she found it difficult to raise any concerns. Since the last inspection visit, one complaint had been made directly to the manager at the home. There were concerning issues which were raised by a family during a review. There was documentary evidence to demonstrate that the manager had followed procedures, and had investigated the concerns appropriately within the timescales set down by the ‘in house’ policy. A written response was sent to the complainant, and highlighted an action plan to show how the shortfalls were going to be addressed. The Commission for Social Care Inspection have not received any complaints about this service since the last inspection visit. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 18 A number of staff were spoken to about their understanding of adult protection issues. Most staff were able to demonstrate a sound understanding of the procedures for adult protection, and were aware that any allegations of abuse must be reported to social services and the Commission for Social Care Inspection. Since the last inspection visit, some progress had been made to ensure that staff received appropriate training to help them to develop awareness and a sound knowledge base on adult protection and safeguarding issues. The manager has put an information file in place, which provides staff with useful information on issues surrounding abuse. This also included the safeguarding adults procedures, and the forms which staff are required to complete in the event of any allegation of abuse. This provides staff with a useful overview on local procedures and the systems in place for holding strategy meetings. Some progress had been made in meeting the previous requirement for all staff to receive training in adult protection. In March 2007, three staff attended a course in safeguarding adults, the manager attended training in May 2007 and training has been scheduled for additional staff in December. The manager said that December was the earliest date that she could obtain in securing this training for staff. As an interim arrangement, and until all staff have been enrolled on this training, the remaining staff team have watched a DVD on safeguarding adults and completed a questionnaire which enabled the manager to assess staff awareness and understanding of the training material. The manager was aware that this type of training should not be used as a substitute for formal training. There was evidence in the supervision programme, that the one to one supervision sessions were used to reinforce good practice in care related topics, which included safeguarding adults. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 19 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 is pleasant and comfortable, and provides residents with a relaxing environment to live, and to invite their friends and family. EVIDENCE: Residents were asked for their views about the environment during the site visit and in surveys, which were sent out to them before the visit. The majority of responses were positive about the environment. Residents who were spoken to said that the home was almost always clean and tidy, and a visiting relative was complimentary about the standards of hygiene in the home. During the site visit, all areas of the home were clean and tidy and there were no unpleasant odours. The manager completed a self-assessment quality assurance document prior to the inspection. In this document, she confirmed that the maintenance of the building was kept up to a good standard by using a system which was set up to Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 20 regularly monitor and assess standards in the home. The document states that quality audits of the building are held monthly, which highlight and help to identify where improvements are needed. There were two domestic staff on duty during this visit, and through discussions with them, it was evident that they took pride in their work and were keen to maintain good standards of hygiene and cleanliness throughout the home. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 21 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. Robust recruitment, and training programmes for staff has been improved and prioritised. Residents using the service can be confident that staff receive appropriate support and training, to ensure that they have the right skills to help them to meet the needs of the people they provide care and support to. EVIDENCE: During this visit, there appeared sufficient staff on duty to meet the needs of the residents in the home. Staff were observed engaging in meaningful conversations, and seemed to respond quickly to any resident asking for support. Since the last inspection domestic hours have been increased by an additional 18 hours each week, so that all days are covered. This increase in hours is reflected in the good standards of cleanliness found in the home during this visit. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 22 During this visit, the manager was able to demonstrate that training was being prioritised in the home. There was evidence available to show that the manager and two senior members of staff were booked on dementia training courses in October 2007 and January 2008. In addition to this, that manager has developed a learning resource file, to included information for staff on dementia care. This is available as a reference tool for all staff and includes a wide range of information including a definition of dementia, signs of dementia, and the different types of dementia. This resource reflects the need for staff to be fully trained and have an awareness of the conditions affecting the people who they support. The manager said that information in the files is also shared with relatives who need support and information on a condition, which may affect their family. The manager has also provided all staff with a comprehensive handbook- ‘working with dementia’. The manager was able to demonstrate that monitoring of staff training had also been prioritised. A training matrix is in place, which provides the manager with a tool to monitor staff training and development needs. The manager said that the supervision process was also used as an opportunity to reinforce good practice. Information provided in the annual quality assurance assessment provides evidence that the manager has confirmed that 50 of staff have, or are working towards NVQ level2 or above in care. Staff who were spoken to confirmed that they had access to training and development opportunities. Since the last inspection, where shortfall had been identified with recruitment procedures, the manager had developed a recruitment policy. This provided information of a clear and structured process detailing the checks and procedures which need to be followed so that residents can be sure and satisfied that all staff employed are suitable for the position they hold. Two staff files were examined and contained the appropriate paperwork and documentation as required by regulation. Files examined contained two written references and Criminal Record Bureau (CRB) checks. It was evident from the information examined, that the manager was regularly auditing files, and was currently in the process of developing staff profiles to include all training certificates, staff photographs, and health declarations. It was pleasing to note in the inspection, that the manager had been pro-active in addressing the shortfalls in staff recruitment from the last inspection visit. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 23 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): 31,33,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager was able to demonstrate that appropriate policies and procedures were in place, so that people can be confident that their safety, health and well-being are protected. EVIDENCE: The manager of the service is now registered with The Commission for Social Care Inspection. She is currently working towards the registered manager award. Since the last inspection the manager has worked towards improving the service, and addressing the requirements and recommendations from the previous inspection. She has put a number of procedures in place to monitor medication systems, and staff training programmes. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 24 Staff who were spoken to said that they found the manager approachable, and that they felt confident in raising any issues of concern. Staff confirmed that they were in receipt of regular supervision. In the self-assessment document, completed by the manager before the inspection, she identified that it was necessary to continually improve staff training and supervision programmes. Information in the assessment document provided evidence and confirmation from the manager, that all policies and procedures in the home had been updated and reviewed. Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 25 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 X X X 3 Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 26 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. Standard OP9 Regulation 13 Requirement All staff members responsible for the safe handling of medication must adhere to and follow the policies and procedures, which are there to ensure the health safety and well being of residents in the home. Timescale for action 01/10/07 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 OP7 Good Practice Recommendations Care plans and reviews should include the signatures of residents and their relatives or representative, to demonstrate that they have been involved in the care planning process. Residents should be consulted on their interests so that their social, cultural, religious and recreational interest are met. 2 OP12 Firbank House Nursing Home DS0000025433.V342068.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Firbank House Nursing Home DS0000025433.V342068.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!