Inspection on 16/02/06 for Firbank Private Nursing Home

This inspection was carried out on 16th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Firbank Private Nursing Home 09/08/07

Firbank Private Nursing Home 19/09/06

Firbank Private Nursing Home 18/07/05

Firbank Private Nursing Home 22/02/05

Firbank Private Nursing Home 27/07/04

Firbank Private Nursing Home 23/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Firbank Private Nursing Home 81 Fir Road Bramhall Stockport Cheshire SK7 2JF Lead Inspector Tracey Rasmussen Unannounced Inspection 16th February 09:20 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 Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 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 Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Firbank Private Nursing Home Address 81 Fir Road Bramhall Stockport Cheshire SK7 2JF 0161 440 8725 0161 439 8828 firbank@smallwoodcarehomes.co.uk woodeaves@smallwoodcarehomes.co.uk Smallwood Homes Ltd 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) Mrs Sarah Catherine Regester Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21), Physical disability (21), Terminally ill (2) of places Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service user may be received in the home who is less than 50 years old, male/female. 18th July 2005 Date of last inspection Brief Description of the Service: Firbank Nursing Home is a care home that provides 24 hour nursing care and accommodation to 21 adult service users. Many of the residents accommodated at the home have high physical dependency needs. The home is privately owned by Smallwood Homes Ltd. Firbank Nursing Home is situated on a quiet leafy residential road in Bramhall. Bramhall village, local shops, churches and Bramhall Park are close by. Local bus services are also available. A small driveway leads to a car park and the main entrance to the home. Outside, to the front and rear of the home, there are pleasant garden areas which are accessible to service users. The home is a two storey building, converted some years ago to a care home. Sixteen bedrooms are single rooms and two are shared rooms. Two single bedrooms and one shared room have en-suite facilities. Assisted bathing facilities are available on both floors. There is one large lounge, which also provides a small dining table. Service users have a choice of spending time in their rooms or in the lounge. Well maintained enclosed gardens at the rear of the home are accessible from doors off the lounge. A variety of adaptations and aids are provided to assist in the nursing of the service users and this includes a passenger lift and hoists. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on 16th February 2006 by one inspector. Since the last inspection the CSCI has received two complaints about services provided by the home, both were unproven, although areas of improvement and development were identified. A tour of the home took place and care records were seen and both residents and staff were interviewed. An immediate requirement letter was issued at the home because there were problems with hot water, infection control and a loose electrical socket that was in use. Many of the requirements made about care plans had not been addressed and a significant number of requirements were made at this inspection in relation to the home environment. The manager was on a training day at this visit and therefore brief feedback was provided to the operation manager. A more detailed feedback was provided over the telephone to the registered manager the day after the inspection. Not all the standards were assessed at this inspection. What the service does well: The home is welcoming and there is a pleasant friendly atmosphere. Staff are relaxed and good humoured with residents and visitors to the home. Residents were very complimentary about living in the home and praised both the manager and staff. The staff team were very caring and committed to the home. More than one staff member said the ‘home was a happy home’. Residents appeared well cared for with attention to hair, nails and clothing coordination. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 6 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. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 7 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 Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 8 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 and 5 Residents have sufficient information to make an informed choice about the home and have their needs assessed. The residents receive confirmation that the home can meet their needs before admission. EVIDENCE: Information packs were readily available at the main entrance to the home. These contained detailed information about the services provided in the home, including a statement of purpose, a service user guide, summary of the last inspection, the home’s complaints procedure and terms and conditions of residency. Information in the packs was comprehensive and offered practical information about the services and standards to be expected. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 9 Twenty-one residents were living in the home and two care plans for newer admissions were examined. Both care files had the home’s pre-admission assessment on file. One of these was quite detailed, whilst the second file contained less detailed information and did not contain the name of the resident. Community care assessments (the single assessment document) were not available on either care file and the operations manager did acknowledge that these were not always requested. Information detailed in the pre-admission assessment was not consistently reflected in the care plan, for example, one resident’s pre-admission assessment referred to Diabetes and there was no care plan for this. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 Residents were treated with respect and dignity. The care planning documentation was insufficient to meet the health and personal care needs of some residents. EVIDENCE: The home was peaceful and welcoming. All residents spoken with were very positive about the quality of care they received at the home and spoke highly of all the staff team. One resident said, “Nurses and all staff are super” another resident said the home had “good staff”. Many of residents living in the home were very frail and dependent but all were assisted to maintain their personal appearance and attention was paid to hair, teeth and nails and to ensuring clothing co-ordinated. Staff spoke to residents in a respectful way and one resident confirmed that her privacy and dignity and personal wishes were respected. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 11 The home’s care planning format had been changed since the last inspection, however the care files examined demonstrated very little improvement with regards the quality of recording. Quality care plan documentation has been an ongoing problem at Firbank. One care file did contain more detail and a care plan for almost each assessed need, however the file was untidy, and care plans were not recorded for MRSA and care of the gastrotomy tube, although published documentation about each was available on the file. One care plan record for pressure care had the actual intervention plan missing and wound treatment records had not been updated for over a month. Evidence that the wound had improved or deteriorated could not be identified. A second care file was only partially completed, in that, a skin integrity assessment and social care assessment had not been recorded. Care plans for known needs had not been written and care plans and assessments undertaken indicated that there was a problem with dietary intake and to monitor weight. No admission weight or subsequent weights were found on the file. Medication practices were not assessed at this visit, however a dedicated treatment room had been created since the last inspection visit and this has increased the storage security of medications in the home. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 12 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 and 14 Lifestyle choices were generally available but records to support the social aspects of the service that may be provided were not. EVIDENCE: Care plan documentation seen did not contain detail about the social lives of the residents before admission to the home nor did it detail the interests or preferences the resident had shown whilst living in the home. A plan for different activities was available for February but from discussion with staff and residents this was not always followed. One staff member was employed to undertake activities on Tuesday and Thursday afternoons but on this visit the employee was on leave. Residents spoken with said their personal preferences that included staying in their own room and not socialising were respected. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 13 At this visit the home had a problem in providing hot water to hot water outlets in the home. This had been an ongoing problem (please see the Environment section of this report). The lack of hot water provision on a consistent basis had potentially limited residents’ rights to have a full bath. Staff said that there was hot water on some days and people could have baths then, but residents could not be guaranteed a bath on the day of their choice. The staff did emphasise that all residents were assisted fully to maintain their personal care despite the lack of a full immersion bath and residents did appear appropriately cared for. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 14 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 and 18 Residents can be confident that complaints are responded to appropriately. Residents are protected from abuse. EVIDENCE: The home has a complaints procedure which is made readily available to people coming into the home. The CSCI has received two complaints about services provided in the home, one was in relation to the quality of care provided to one resident. This complaint was unproven, although concerns were identified about the quality of care planning documentation. The second complaint was in relation to the provision of services to an adjacent unregistered property. This complaint was also unproven. Staff interviewed demonstrated understanding of abuse and the action to be taken if abuse is suspected. Staff have been applying for places on Stockport local authority’s ‘Alerter’ course and this is considered good practice. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 15 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, 23, 24, 25 and 26 Residents live in a clean and tidy home but do not have access to consistent running hot water. Internal maintenance, redecoration and refurbishment is not satisfactory and some shared bedrooms are not large enough. EVIDENCE: Some maintenance work had been undertaken since the last inspection, the home has had a new roof and a dedicated medication storage room has been created. New equipment such as adjustable profiling beds had been provided to all residents in the home. However at this inspection an immediate requirement letter was issued for the registered person to address some areas of serious concern. References to these are also included in standard 38. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 16 The home has had problems in the past in ensuring a continuous hot water supply to residents’ bedrooms and other hot water outlets and assurances have been provided that this would be addressed. The manager did state that a new central heating boiler was installed last October but this didn’t fully resolve the problem. Sampling of the water outlets in the bedrooms at this visit identified that at least two thirds of them had no hot water. One resident was very complimentary about the care and the staff but stated she rarely had warm water available in her room. Staff did not know if any action was being taken to improve the hot water supply in the home and seemed to accept the problem as the ‘norm’. The home had also had severe leak four days previously, early on the Sunday morning, from the water tank in the loft. The leaking water had flooded down the staircase and had soaked some of main electrics and the carpets in the home. The nurse on duty at the time of the flood had been refused permission to call out a plumber to address the problem and, at the time of this visit, a plumber had not been out to address the problem. Staff had to leave a bath water outlet tap running continuously to prevent further flooding in the home. The general manager for the company stated that he had tried to get the plumber used by the home to come out prior to the inspector’s visit. The general manager later confirmed that the plumber would be out later on the day of the inspection. The home was clean and odour free and domestic staff were observed to be thorough in undertaking their duties. However, there were areas inside the home that showed evidence of wear and tear. Some rooms needed redecorating and some furnishings in some bedrooms were damaged with edging strips missing from vanity units and chests of drawers. Domestic staff were re-hanging curtains that fallen off the rails and it was reported that hooks to fit the rails were no longer available because the rails were very old. Domestic staff were also providing a cleaning and meal delivery service to the adjacent property. Additional hours had not been provided to the domestic staff to allow them to undertake these additional duties, which has left Firbank with a reduction of actual domestic hours used in the home. The manager did state that a review of the role and responsibilities of the domestics was underway. Two of three shared bedrooms were small. The ground floor shared bedroom was undersized for two residents to share. Beds were very close together and one resident could only sit on a commode chair with a breakfast table if her bed was pushed up next to the other resident’s bed. These residents could only have a single wardrobe each because there was no space to accommodate the normal usual double wardrobe. Facilities in one of the shared rooms on the first floor were also cramped. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 17 The home’s laundry facilities are based on the first floor and access is through a bathroom. The flooring in the room needs replacing, as protective tape used at some time in the past to repair the flooring was worn and threading. It was reported that the plumbing problems in the home had also affected the quality of the laundry service, in that, water temperatures to guarantee the correct cleaning of foul and infected laundry could not be consistently reached by the machine and that woollens had been ruined by hot water entering the machine through the cold-water inlet. One electrical socket in use in the home required urgent repair and staff stated that this and other sockets in the home that needed repair had been reported repeatedly. (See standard 38). One bedroom was held open by a stone and chair whilst other bedroom doors had automatic electronic door holders on them. The manager did state that this bedroom and a second bedroom needed magnetic openers and this would be looked at in conjunction with the fire risk assessment in the near future. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 18 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): 28 and 29 Staff are vetted correctly and trained to do the job. EVIDENCE: All staff spoken to were positive about working in the home. One staff member said she “loved working in the home”. Another staff member said they were a “happy team”. Residents were also complimentary about the staff, comments such as “lovely staff” was heard on more than one occasion. NVQ training is well established in the home with over 50 of the staff having the level 2 qualification. A number of staff also have NVQ level 3. Employment records were not assessed in detail however, the home does ensure CRB applications and PovaFirsts are obtained before staff commence working in the home. One new staff member spoken to confirmed this and detailed the induction training she had received. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 19 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, 33, 35 and 38 The management of the home promotes the wellbeing of the residents but health and safety issues are not addressed in a timely way. Accounting and financial procedures are not consistently safe. EVIDENCE: The manager in the home has completed NVQ level 4 in management. Staff and residents were complimentary about the manager’s style. The manager works a significant portion of her time as the nurse on duty which reduces her time to actual manage and address administrative tasks which are a part of her role and responsibility. The manager’s management hours should be increased to ensure she can address the issues identified in this inspection report. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 20 Quality assurance systems are in place and this includes user questionnaires and auditing of different aspects of the service, however both questionnaires and audits had not been undertaken for some months. The frequency of the formal monitoring being undertaken in the home should be increased to ensure standards of service are maintained. Formal notifications to the CSCI of significant events occurring in the home, such as the lack of hot water and the recent water leak, had not been made. The home does hold personal money for residents. Each resident’s money is held separately with an individual accounting record. The record sheet would benefit from having separate debit and credit columns to allow quicker tracking of the residents’ money. Receipts were not available for debit transactions. Three lots of residents’ monies were checked. Two were correct. The third monetary balance did not correspond with the written account. Examination of the written record identified that the last entry had only been partially filled out and details of the expenditure and amount had not been recorded. This is poor practice. The manager does undertake regular checks of balances and record sheet. A number of issues in relation to health and safety were identified at this visit and did cause concern, requiring the issuing of a serious concern letter. The section on the Environment lists these issues. Staff were very aware of their health and safety responsibilities and did try to ensure practices were safe in relation to carrying hot water from the geyser in the kitchen to residents’ bedrooms or to cleaning buckets. However, risk assessments had not been undertaken and access to water thermometers to ensure water did not scald residents were not readily available. One electrical double socket was hanging off the wall but remained in use, despite staff reporting this. Another electrical socket had been taped over to prevent use but had clearly been in use. Concerns were also identified regarding the potential increase of the risk of cross infection due to the lack of hot water for staff to wash their hands properly between tasks. The home has also had an electronic nurse call system installed for the attached property, Rose Garden. The manager stated that no caring services are provided by Firbank at Rose Garden, however the active electronic connection between the two properties indicates the possibility that nursing and care staff may be called on to provide services to the unregistered service. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 21 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 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x 1 2 1 1 STAFFING Standard No Score 27 x 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 x x 1 Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 22 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 OP3 Regulation 12,14,15 Requirement The registered person must ensure that residents’ needs identified in the pre-admission assessment have a corresponding plan of care. The registered person must ensure that pre-admission assessments are recorded in detail and include the potential new resident’s name. The registered person must ensure that residents’ care plans set out in detail the action needed to be taken to ensure all aspects of the health, personal and social needs of the service user are met. The registered person must ensure that wound assessment and care plans are evaluated regularly and this includes reference to the size, depth and tissue appearance. (Timescale of 31/08/05 not met). Timescale for action 30/03/06 2 OP3 12,14,15 30/03/06 3 OP7 12, 14,15 15/04/06 4 OP8 12,13 30/03/06 Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 23 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. 5 Standard OP8 Regulation 12,13,16 Requirement The registered person must ensure that the type and settings of all pressure relieving equipment used for each resident is recorded in their plan of care. (Timescale of 15/08/05 not met). The registered person must ensure that care plan documentation includes the social aspects of the resident’s past and present life. The registered person must ensure facilities provided in the home promote residents’ rights to choose to bathe upon request. The registered person must ensure that residents in shared bedrooms are provided with sufficient personal space to allow each person the opportunity to sit out in an easy chair without encroaching on the other occupant. The registered person must ensure that residents in shared rooms have the required amount of furnishings identified in the national minimum standards and this is placed within the vicinity of the resident’s bed. Timescale for action 30/03/06 6 OP12 12 15/04/06 7 OP14 12,16 22/02/06 8 OP23 12,16,23 30/03/06 9 OP24 12,16,23 30/03/06 Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 24 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. 10 Standard OP25 Regulation 16,23 Requirement The registered person must ensure that there is hot water readily available in all rooms with a hot water outlet. The registered person must ensure that safe procedures are implemented to prevent and reduce the risk of cross infection in the home. The registered person must ensure that the number of domestic hours provided in Firbank nursing home is not reduced by adding additional tasks outside the home. The registered person must ensure that all staff who have access to residents’ personal monies record all transactions in detail and provides receipts for any expenditure. The registered person must ensure that the CSCI is notified in writing of all incidents detailed in Regulation 37. The registered person must ensure that risk assessments are undertaken to ensure safe working practices. Timescale for action 22/02/06 11 OP26OP38 13,16,23 22/02/06 12 OP26 12,13,18 30/03/06 13 OP35 13,16,17 30/03/06 14 OP38 37 30/03/06 15 OP38 13,16,23 30/03/06 Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 25 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. 16 Standard OP38 Regulation 13,16,23 Requirement The registered person must ensure staff have easy access to hot water to promote good standards of personal hygiene and prevent cross infection. The registered person must ensure that all electric sockets in the home are maintained in safe working order. The registered person must ensure the electric socket in room F3 is safe to use by 5pm 17th February 2006. The registered person is required to supply the CSCI with a copy of the home’s Periodic Electrical Inspection report by return of post. The registered person must ensure that staff have an emergency procedure to follow in the event of a significant occurrence in the home. The procedure must contain the contact details of service engineers so appropriate people address the problem immediately. The registered person must ensure that the nurse call system between Firbank and Rose Garden is deactivated. Timescale for action 22/02/06 17 OP38 13,16,23 24/02/06 18 OP38 13,16,23 17/02/06 19 OP38 13,16,23 28/02/06 20 OP38 13,16,23 30/03/06 21 OP38 1,2,12,13 28/02/06 Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 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 2 3 4 5 6 7 8 Refer to Standard OP3 OP12 OP18 OP19 OP23 OP31 OP33 OP35 Good Practice Recommendations The registered person should ensure that community care assessments are consistently obtained for all new admissions into the home. The registered person should increase the number of dedicated activity hours, so that activities can be provided each day. The registered person should ensure that all staff attend one of the ‘Alerter’ training courses provided by Stockport Social Services. The registered person should ensure that internal redecoration and refurbishment are undertaken The registered person should reduce the number of shared bedrooms to provide spacious single accommodation and promote the privacy and dignity of the resident. The registered person should increase the number of hours the manager is supernumerary to allow her time to fulfil the management aspects of her role. The registered person should ensure quality assurance monitoring, audits and questionnaires are undertaken on a regular basis. The registered person should ensure that residents’ financial transaction sheets have separate debit and credit columns. Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Firbank Private Nursing Home DS0000017294.V278226.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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