Inspection on 28/09/07 for Fisher Close Nursing Home

This inspection was carried out on 28th September 2007.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fisher Close Nursing Home 05/08/08

Fisher Close Nursing Home 28/11/06

Fisher Close Nursing Home 03/02/06

Fisher Close Nursing Home 13/09/05

Fisher Close Nursing Home 21/02/05

Fisher Close Nursing Home 23/09/04

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Fisher Close Nursing Home Grangewood Farm Estate Walton Chesterfield Derbyshire S40 2UN Lead Inspector Tony Barker Unannounced Inspection 28 September & 1 October 2007 09:35 th st Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 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 Fisher Close Nursing Home DS0000002056.V345621.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 Adults 18-65. 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. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fisher Close Nursing Home Address Grangewood Farm Estate Walton Chesterfield Derbyshire S40 2UN 01246 200138 01246 202667 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) Enable Care & Home Support Limited June Stocking Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2006 Brief Description of the Service: Fisher Close is situated in a residential area approximately 2 miles from the centre of Chesterfield. The Home comprises three bungalows, each providing nursing and personal care and support for up to five adults with learning disabilities. Although the Home is registered and managed as one establishment, each bungalow has its own separate nursing and care staff group and dedicated facilities including aids and adaptations. All residents are accommodated in single bedrooms and three of these have en suite facilities. Each bungalow has its own garden area, accessible to residents. Transport is provided for residents. There is a car park to the front of the bungalows. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 9 hours over two days and was a key unannounced inspection. In the Manager’s absence the Acting Manager, one staff nurse and two support workers were spoken to. The residents had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. Records were inspected in Bungalow 3 and there was a tour of that building. Two residents from that bungalow were case tracked so as to determine the quality of service from their perspective. Survey forms were posted to the relatives of ten residents and six were completed and returned. The information supplied in this way was analysed before the inspection and the outcomes included in the inspection process and reflected in this report. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire was reviewed prior to this inspection. The Home’s fees were stated on Service Users’ Guides as ranging from £1095 to £1821 per week. A copy of the last inspection report, from the Commission for Social Care Inspection (CSCI), is available to residents and visitors in the Manager’s office. What the service does well: What has improved since the last inspection? Care plans and risk assessments were being kept under review. Staff had been provided with training in the areas of Moving & Handling and Infection Control. The Manager had applied to the Commission for Social Care Inspection to be the Registered Manager and had been approved in this role. All requirements and recommendations, made at the last inspection, had been met. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual written needs assessments were in place before people were admitted to the Home so that their diverse needs were identified and planned for. EVIDENCE: Most of the residents at Fisher Close had lived in the Home for many years and some residents had lived here since it opened. There hd not been any new admissions since the previous inspection. Assessments of residents’ needs had been completed prior to their admission to the Home and had been updated when their needs changed. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had individual plans of care which well demonstrated that their health care needs were being met. A ‘person centred approach’ had been started to ensure that residents’ unique needs were focussed on. EVIDENCE: The care files of both case tracked residents were examined. They contained a very good range of health related care plans based on ‘problem related’ topics. They were well organised with associated objectives, both general and specific, and were being formally reviewed on an annual basis. Records showed that these annual care plan review meetings were well attended. The in-house evaluation of the care plans was aided by regular notes relating to each care plan topic but the actual evaluations were somewhat sporadic in frequency. Care plans also included a record of residents’ likes and dislikes and of their social and emotional needs - but there were no objectives associated with these needs to guide staff in holistic care planning. The activities in which residents participate were listed, with brief notes, but again there were no associated objectives. However, the Inspector was pleased to note that each Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 10 resident had a ‘Personal Planning Book’ that was ‘person centred’ throughout. This Book included ‘My Goals’ and ‘My Action Plan’ although these were blank on both the files examined. The Staff Nurse in Charge, on the first day of this inspection, had not received training in ‘Person Centred Planning’ and thought that the staff group were not fully clear about the aims and functions of this approach. Because of the nature of their disabilities the residents were unable to fully participate in making choices about their lives. However staff encourage participation and support this and the Staff Nurse in Charge gave an example of one of the four residents in Bungalow 3 being able to choose between items identified by staff when the person’s bedroom is being refurnished. This resident uses Makaton sign language and this improves the communication between resident and staff. The Staff Nurse went on to say that the other three residents are only able to make personal choices of a simpler nature, such as between two yoghurts. Wherever possible, choices are offered in relation to menus, activities and daily routines, for example. Staff were observed and heard to be talking to residents sensitively and with warmth. Risk assessments were in place, along with associated Action Lists, in relation to a good range of topics. These extended to guidance for staff, who attend Enable’s day centre with residents, on the symptoms of different epileptic seizures. The support worker spoken to gave examples of residents taking responsible risks. These included going into a café with staff – an example given in relation to the risks associated with the potential for a resident to display disruptive behaviour in public places. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provided activities and services that were age-appropriate and valued by service users and promoted their independence. EVIDENCE: The support worker spoken to gave examples of residents being involved in personally valued and fulfilling activities. These examples included residents showing pleasure at hearing music and the smiles at being in open spaces. The Inspector was informed that all but two of the current group of 14 residents attend day services. Mainly, this is to Enable’s own day service provision in Tibshelf although two attend Social Services day services. The Staff Nurse in Charge said that all residents have at least four day-trips out a year, together as a group. She said residents went to Twycross Zoo last week and there were plans to take a trip to Blackpool later in October. In Bungalow 3, all the residents took an annual holiday this year to Butlins in Skegness. Last year they had gone to Eurodisney in two groups of two. The Manager, in the pre-inspection, Annual Quality Assurance Assessment (AQAA), Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 12 questionnaire stated that she was looking to develop more individual programmes and activities for residents. The support worker spoken to described a range of age-appropriate activities in the local community that residents were involved in. These included the hairdresser, café, pub, swimming pool and food and clothes shops. Additionally, residents had access to specialist facilities such as the spa and Snoezelen facility (sensory rooms) at Ashgreen. It was noted that sometimes trips out can be constrained by the availability of minibus drivers and escorts and new regulations relating to the drivers of these vehicles. The support worker spoke of residents generally having good contact with their family members. They receive visits and a number spend time at home with relatives. These contacts are encouraged by the Home. Residents’ need to be treated with dignity and for privacy is recognised in written risk assessments that address the lack of locks on bedroom doors. These risk assessments refer to control measures, to address this issue, that include knocking on the door before entering the room. The support worker confirmed this practice and gave other examples whereby residents’ privacy needs were being met – for example, by the provision of en-suite showers. The Staff Nurse in Charge also commented that staff may lock a bathroom door, while staff are with the resident, to prevent intrusion from another resident. The support worker confirmed that daily routines promote residents’ independence and that they are flexible to reflect activities and individual residents’ behaviour. This would include the timing of meals. Food stocks were at a good level and included fresh fruit, salads and vegetables. Menus were examined and these showed that residents were provided with a varied and nutritious diet. Residents’ food likes and dislikes were recorded. The support worker spoken to explained that, currently, one resident from Bungalow 3 was involved in food shopping. A member of support staff was observed helping a resident, who was unwell, to eat. The staff member said she would normally be encouraging the resident to independently eat the meal with a knife and fork. It was also noted that this resident’s preference for eating separately from the communal dining table had been actioned. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home was providing residents with personal support in the way they preferred and required and was very well meeting their health needs, except that improvements to some practices regarding residents’ medicines was needed. EVIDENCE: The Home provided a good range of equipment that maximised residents’ independence, including specialist beds and chairs. Some residents were using Makaton sign language – for example, to sign when wanting a shower or to have nails and hair seen to. Some staff had been provided with Makaton training and a Makaton folder was seen. One resident used to make it clear that they wished not to have a bath – this was addressed by providing this resident with an en suite shower. Each bungalow had a dedicated Snoezelen room and sensory equipment was also seen in Bungalow 3 bathroom and in bedrooms. Music videos were being played on the lounge television in Bungalow 3 during this inspection and the residents in there appeared calm and relaxed. The Acting Manager said that an independent advocate had been involved with residents in Bungalows 1 and 2. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 14 There was evidence of residents’ health care needs being very well met. Care plans extensively recorded health care needs and objectives. There were several records indicating regular monitoring of personal health conditions. These included epilepsy, weight, food intake and continence. Risk assessments to address tissue viability and nutrition were being reviewed monthly. Health appointments were well recorded and indicated a wide range of health professionals involved. There were separate notes in relation to psychology and speech therapy involvement. In Bungalow 3 the alternative therapies of reflexology and Reiki were being provided to its residents. Residents’ ‘Personal Planning Books’ had the potential to take a ‘person centred approach’ to their health care needs. The Home is commended on its provision of health care to the residents. Medication Administration Record (MAR) sheets were examined and were generally satisfactory except for several examples of handwritten entries that had only one signature beside them. There was a record of sample nursing staff signatures/initials and photographs of each resident, to minimise mistakes. Qualified nursing staff were administering medication plus one support worker. This worker had been provided with training in the safe use of medicines. Several residents were being administered medication on a ‘prn’ as and when required – basis. These occasions were being recorded on MAR sheets with further details on the rear of the MAR sheets. However, the details of one dose of chlorpromazine ‘prn’, administered to a resident on 29 September, had not been recorded. Also, the wording on the MAR sheet was unclear – it stated in print, “Take three times a day as directed” and had a handwritten addition of, “When required”. There was no written protocol for the use of this ‘prn’ medication although protocols were in place for other ‘prn’ medicines. The quality of some of these protocols could be improved. For example, the protocol for one resident’s ‘prn’ rectal diazepam did not include the maximum dose in a 24 hour period. Another resident’s ‘prn’ chlorpromazine protocol just mentioned “agitation” as the trigger for administration. The protocol was cross-referenced to the resident’s care plan which was good practice although the wording, “If behaviour persists” would have been improved by providing a timescale. The storage of all medicines, including controlled drugs, was satisfactory. The remaining number of one case tracked resident’s controlled drugs was cross-referenced against the running total in the Register and found to be correct. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures for handling complaints and abuse were in place, ensuring that residents were fully protected. EVIDENCE: The Home had a satisfactory complaints procedure. The complaints procedure, specifically designed for the residents to read, was very well designed with photographs, drawings and symbols. An appropriately designed complaints book was in place in Bungalow 3 – it had no entries. All relatives who responded to the postal survey confirmed that they knew how to make a complaint about the care provided by the Home if they needed to. The Home had a Policy on ‘Safeguarding Adults’ and a copy of the Derbyshire Safeguarding Adults Procedure. The Home’s policy was not fully clear about the need to immediately contact Social Services, as the lead agency, in the event of suspicion of abuse of a resident. The Acting Manager could find no written policy on Whistle Blowing although the support worker who was spoken to showed a good understanding of this topic. All staff had attended training on ‘Safeguarding Adults’ and on SCIP (Strategies for Crisis Intervention and Prevention). Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were living in a comfortable, hygienic and homely environment. EVIDENCE: The Home consisted of three adjacent bungalows, each with five bedrooms of which three had en suite showers. Each bungalow also had a bathroom – two with a ‘rising bath’ and overhead track with hoist and Bungalow 3 had a standard bath and a Jacuzzi. It was in Bungalow 3 that there were two en suite showers and there were plans to provide a specialist bath in this bungalow. Each bungalow had a dedicated Snoezelen room. There was a high standard of decoration and furnishings throughout the three bungalows and they were well maintained. The five bedrooms in Bungalow 3 were viewed. One was vacant – the others were very well personalised and included equipment designed to provide visual and auditory stimulation. The Home was well maintained. A summer house and gazebo were provided within attractive gardens outside. The Home is commended on its high environmental standards. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 17 The support worker spoken to described very good practice regarding the movement of infected material within the Home and its disposal. The Manager, in the pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire stated that 43 of the total staff group of 46 had received training in Infection Control. There were sluicing sinks and high temperature washing machines in each bungalow. The Home was clean and hygienic with no offensive odours. One relative remarked that, “Fisher Close is very clean”. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 &35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home had an effective staff team of well-trained workers to ensure that residents were safe and their needs were met. EVIDENCE: Nine of the thirty one social care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above. This did not meet the National Minimum Standard to maintain a staff group with at least 50 qualified staff and was less than at the last inspection. Fourteen residents were accommodated at the time of this inspection. The Acting Manager stated that there were normally three members of staff on duty in each bungalow and this could rise to four when day services are taken account of. The Staff Nurse in Charge said that all residents need a one to one staffing ratio while out of the Home. There were just two male staff working at the Home. The Staff Nurse said it was policy for female staff to accompany a male colleague when dealing with the personal care of a female resident. Staffing rotas were not examined on this occasion. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 19 The standard of staff recruitment practices could not be assessed on this inspection as, in the Manager’s absence, the Acting Manager did not have access to staff members’ personal files. At the previous inspection, records indicated that the Home’s recruitment policy and practices were being followed. Two staff in Bungalow 3 were asked about their induction experience after taking up employment at the Home. This appeared to be satisfactory but they were not given the opportunity to undertake a formally recognised and accredited induction course until they had been in post for 12 months. The ‘training matrix’ at Bungalow 3 indicated that staff were being provided with all statutory training, although it was not fully up to date. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some poor health and safety practices could compromise residents’ safety. EVIDENCE: The Manager had worked with adults with learning disabilities for 23 years. She qualified as a RNMH (Registered Nurse in Mental Handicap) in 1987 and had a qualification in management equivalent to NVQ level 4. A Business Plan had been developed for the Home and this was examined and found to be satisfactory. Satisfaction questionnaires were sent to relatives annually. Those completed in July 2007 were all seen to be positive. Questionnaires for residents’ completion had been completed in 2006 – these made appropriate use of simple images to indicate satisfaction or otherwise with the service provided. It appeared that no other groups, such as external professionals, had been sent a questionnaire as part of the Home’s quality Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 21 assurance system. Unannounced visits to the Home, on behalf of the Registered Provider, were being made as detailed in Regulation 26 but not at the required monthly frequency. The only visit sheets available related to visits in January, July and August 2007 and staff thought these visits did not take place monthly. Cleaning materials were being stored in a kitchen wall cupboard. On the first day of this inspection this was an unlocked cupboard but a lock was quickly fitted when the potential risks were pointed out. Product data sheets, as required by the Control Of Substances Hazardous to Health (COSHH) Regulations were found in two folders, which was confusing, and neither referred to the bleach being kept. Good food hygiene practices were being followed, including safe food storage. Environmental risk assessments for all areas within Bungalow 3 were in place – these were last reviewed in March 2006. Accidents at Bungalow 3 were being recorded in either of two places, which was confusing. Records of fire drills indicated that the last one was held in March 2006 and the Acting Manager had no recall of one since. Records of fire alarm tests were in place although the weekly occurrence of these had not been recorded since 30 August 2007. Electrical and gas equipment was being checked at appropriate intervals. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 X 3 X 3 X X 1 X Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13(2) Requirement A written protocol, on the use of ‘prn’ - as and when required medication, must be provided in respect of all residents who are administered medication in this way. These protocols must be explicit in order to minimise different interpretations and ensure the safety of residents. The dosage and frequency of all medication to be administered must be clearly recorded on MAR sheets to ensure that that residents receive the correct levels of medication. Product data sheets, as required by the Control Of Substances Hazardous to Health (COSHH) Regulations must refer to the bleach being kept, and include first aid measures in relation to this substance. Alternatively, this substance should be removed from the Home. This will reduce potential risks to staff and residents. Fire drills must be carried out at least twice a year to ensure the safety of all residents and staff. Timescale for action 01/11/07 2. YA20 13(2) 01/11/07 3. YA42 13(4)(c) 01/11/07 4. YA42 23(4)(e) 01/11/07 Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 24 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. Refer to Standard YA6 YA6 Good Practice Recommendations The in-house evaluation of care plans should take place at least every six months. Care planning should be holistic. Care plan objectives should be developed that reflect residents’ social, emotional and recreational needs as well as their health needs. Staff should receive training in the aims, functions and development of a ‘person centred approach’ and residents’ ‘Personal Planning Books’ should be developed. Handwritten entries on medicine records should be accompanied by two staff signatures to ensure a clear audit trail. The details of all occasions when ‘prn’ - as and when required – medication is administered should be recorded. The Home’s policy on ‘Safeguarding Adults’ should clearly indicate the need to immediately contact Social Services, as the lead agency, in the event of suspicion of abuse of a resident. At least 50 of social care staff should hold a National Vocational Qualification (NVQ) to level 2 or above. All records referred to in Schedules 3 & 4 of the Regulations, including a record of all persons employed at the Home, should at all times be available for inspection. All newly appointed staff should be provided with induction training to Skills for Care standards within the timescales laid out by that body. Satisfaction questionnaires should be sent to service users’ care managers or other external professionals. Monthly quality monitoring visits should be made to the Home consistently. Product data sheets should be kept together in one folder to ensure quicker access to important information such as first aid measures. Environmental risk assessments should be reviewed at least annually. Accidents should be recorded in one place. Accidents to staff and to residents can be kept separately. Records should be consistently made of weekly fire alarm DS0000002056.V345621.R01.S.doc Version 5.2 Page 25 3. 4. 5. 6. YA6 YA20 YA20 YA23 7. 8. 9. 10. 11. 12. 13. 14. 15. YA32 YA34 YA35 YA39 YA39 YA42 YA42 YA42 YA42 Fisher Close Nursing Home tests. Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Fisher Close Nursing Home DS0000002056.V345621.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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