Inspection on 21/06/05 for Five Acres Nursing Home

This inspection was carried out on 21st June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Five Acres Nursing Home 16/07/07

Five Acres Nursing Home 31/05/06

Five Acres Nursing Home 16/12/05

Five Acres Nursing Home 01/03/05

Five Acres Nursing Home 26/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Five Acres Nursing Home Five Acres Simpson Village, Milton Keynes Bucks MK6 3AD Lead Inspector Christine Sidwell Announced 21st June 2005 9:30am 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 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. Five Acres Nursing Home Version 1.10 Page 3 SERVICE INFORMATION Name of service Five Acres Nursing Home Address Five Acres, Simpson Village, Milton Keynes, Bucks, MK6 3AD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01908 690292 01908 696244 Five Acres Nursing Home Ltd Care Home with nursing 32 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (22) of places Five Acres Nursing Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st March 2005 Brief Description of the Service: Five Acres is a privately owned care home registered to provide personal and nursing care for thirty-four older people over the age of sixty five. Five Acres is an older building set in pleasant grounds in Simpson. There is a combination of single and shared rooms, although most of the shared rooms are currently used as single rooms. The home has a lift, and grab rails in some of the corridors and bathrooms. The home has seven toilets, three bathrooms and disabled bathing facilities. There is a dining area and two lounges. The village of Simpson is situated on the outskirts of Milton Keynes, with good public transport links into the city centre. There are qualified nurses, supported by a team of carers, on duty at all times. There is an experienced management team. Five Acres Nursing Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of an announced inspection, which took place over two days and covered most of the National Minimum Standards of the Care Standards Act 2000. Policies, procedures and records were examined and care practices were observed. A tour of the building took place. The proprietors, manager and a number of nursing, care and ancillary staff members were spoken with. Five resident’s families were also spoken with. Comment cards, distributed prior to the inspection were received from six relatives, two residents and the general practitioner. What the service does well: What has improved since the last inspection? The staffing levels have improved since the last inspection and a stable staff team is now developing. Regular training programmes have been implemented. Care plans have improved, although further improvement is still required to ensure that service users are involved in their care planning and that all their needs are identified. Medication policies and procedures have improved and Five Acres Nursing Home Version 1.10 Page 6 resident’s allergies are now recorded. Nutritional assessments are now undertaken and residents are weighed regularly to detect changes in weight and ensure that appropriate action is taken. The home’s recruitment policies and procedures have been improved and residents are protected by the fact that staff are not now employed without the appropriate checks being undertaken. Resident’s personal allowance is now being handled correctly to safeguard them from financial loss. What they could do better: Ensuring that all entries to the care plans are made contemporaneously and demonstrating the involvement of residents and their families would further improve the care plans. Adopting the guidance of the Alzheimer’s Society on the development of person centred care plans would improve the care plans of residents who have dementia. The manager should ensure that all residents who have a social service care management plan are reviewed annually. Ensuring that there are five portions of fruit and vegetables on the menu daily, and that the evening soft option is on the menu, would further improve the nutritional quality of the menu. Although the complaints policy appears to work well, it could be improved by ensuring that all families are aware of how to make a complaint should they need to do so. The environment and entrance to the home could be improved by providing a discrete unobtrusive area for the general and clinical waste bins, out of sight of residents and visitors. The laundry equipment has recently been upgraded, although the laundry itself could be further improved by the provision of a level, impermeable floor surface. The health and safety systems would be enhanced by undertaking an audit of the systems against the criteria described by the Health and Safety Executive and developing an action plan to address any deficiencies. The recommendations of the environmental health officer should be implemented. Height adjustable beds should be provide for residents receiving nursing care. The effectiveness of the staff team and the knowledge and skills that they bring to the care of residents could be improved by having a plan in place to ensure that fifty-per-cent of care staff hold the National Vocation Qualification in Care at Level 2 or above. There is also a need to ensure that the staff are appropriately qualified in the care of residents with dementia to ensure that the complex needs of this group are met this group can be met. Formal supervision has been established. There is a need to ensure and that staff Five Acres Nursing Home Version 1.10 Page 7 receive regular supervision to ensure that their development is maintained and that their skills and knowledge is increased to enable them to improve the quality of care that they offer residents. A systematic quality assurance programme should be introduced which takes into account the views of residents and their families. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Five Acres Nursing Home Version 1.10 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Five Acres Nursing Home Version 1.10 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4, 5 and 6 The home’s literature and the opportunity to stay for a trial period or for respite care give the potential resident, and their family, the information that they require to decide whether they wish to move to the home. The admission policies and procedures work well giving both the home and the potential resident the confidence that the home can meet their needs. The nursing and care team have the skills to meet the needs of the frail elderly resident and are building up their skills in caring for the frail elderly resident who has dementia or complex problems. EVIDENCE: The home has a statement of purpose, resident’s guide and brochure, which collectively describes the care and facilities on offer. Potential residents have the opportunity of a trial stay before deciding to move to the home on a permanent basis. The home also offers respite care. The manager assesses potential residents before admission to the home to ensure that their needs can be met. This was confirmed by a resident’s daughter who said that the manager had been to see her mother before she moved to the home and that she was pleased with care offered. The care manager’s initial assessments are on file. All residents have a care plan. The home does not normally take emergency admissions but has a policy to cover Five Acres Nursing Home Version 1.10 Page 10 this if necessary. Where an urgent admission is required from hospital the manager will assess the potential resident in hospital before admission. The staffing levels are improving and the newly appointed manager is gradually building a team of qualified nurses and carers. A training programme has been introduced, including training in dementia care. Not all staff have had this training yet. The ability of the manager and qualified staff to ensure that the care they offer is in line with up to date guidance provided by the Nursing and Midwifery Council, The Health Protection Agency, The Alzheimer’s Society and other relevant agencies would be improved by having a computer and internet access at the home. It is recommended that the proprietors consider this. Specialised health services are accessed via the general practitioner and are available from the local Primary Care Trust (PCT), Mental Health and Hospital Trusts. The home does not offer intermediate care. Five Acres Nursing Home Version 1.10 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9 The standard of care planning in the home has improved and residents’ needs are identified and a plan of care to meet them is drawn up. Adopting the guidance of The Alzheimer’s Society on person centred care planning would enhance the care of those service users who have dementia. The health needs of residents are identified and are met by the local primary and secondary health care services, with evidence of multidisciplinary input. The systems for medication administration have improved and residents receive their medication in a safe and timely way. EVIDENCE: Five care plans were selected at random and examined in detail. The content and organisation of the care plans has improved since the last inspection. Those seen had evidence on file of assessment and plans to meet resident’s main activities of daily living. They had been updated monthly although this update should be more thorough. The daily entries had been signed. Risk assessments had been undertaken. There is a need to ensure that entries are made contemporaneously, dated and signed by the person making the entry. This includes the night staff. Not all residents have had an annual review by their care manager and there is a need to ensure that these are completed. Not all care plans had been signed by the resident or their family. The manager said that the resident and their family would be involved in care Five Acres Nursing Home Version 1.10 Page 12 planning at the assessment and development stage. There is a need to ensure that this is documented in some way. The care of those residents who have dementia would be further enhanced by incorporating the advice of the Alzheimer’s Society’s booklet on person centred care plans. All residents were seen on the day of the inspection. All were well groomed. Most had had their hair dressed although one or two required this. The care plans seen had evidence that service users are assessed as to their risk of developing pressure damage. One service user has pressure damage and his care plan showed that the appropriate interventions were in place. The home has a number of specialist cushions and mattresses for residents who are at high risk of pressure damage. Resident’s continence needs are assessed by the home’s nursing staff and the local Primary Care Trust (PCT) supplies the appropriate aids. The home has a good falls assessment document, which seeks to identify the reasons why a resident might fall to enable a plan to be developed. The care plans seen contained nutritional assessments. Residents are weighed monthly. One resident had lost weight and a dietician’s advice had been sought. The day of the inspection was hot and all residents had a drink and carers were observed to be helping those who could not drink unaided. The residents seen appeared to be well hydrated. Residents have the choice of remaining with their own general practitioner. Where this is not possible the PCT will allocate a general practitioner. The manager reports that she has been able to develop a better relationship with the local general practitioners who are more willing for residents to be registered with them than in the past. There was evidence in the care plans that residents had access to the specialist services of the local Healthcare Trusts. There are medication policies in place. Records are kept of medication received and leaving the home. The medication administration records are completed correctly. Resident’s allergies are now recorded. The controlled drugs are stored and recorded correctly. There is a new clinical room,, where medication is stored. The nurses stated that medication is not administered covertly. A pharmacist prepared dosette system is in use and the pharmacist reviews medication practices on a quarterly basis. Five Acres Nursing Home Version 1.10 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15 The home’s staff team are welcoming to families and friends, enabling residents and their families to maintain contact where they wish. The meals in the home are good and offer choice and variety as well as catering for specific dietary needs. EVIDENCE: Six relatives returned the comment cards distributed as part of the inspection and all said that they were welcome to visit the home at any time and that they could see their relative in private if they wished. The resident’s guide gives information on the home’s policy of encouraging visitors and offering privacy when receiving visitors, making phone calls and opening and reading mail. There are three meals a day supplemented by morning coffee, afternoon tea and an evening drink. Residents have a choice of main meal. The menus appear nutritionally balanced although there is a need to ensure that five portions of fruit or vegetables are available every day. There is also a need to ensure that the soft option at the evening meal is on the menu. The chef takes pride in ensuring that residents enjoy their meals and told the inspector that alternative meals could be provided if a resident wishes. The two residents who returned the comment cards and those spoken to on the day of the Five Acres Nursing Home Version 1.10 Page 14 inspection said that they enjoyed the food. The menu on the day of the inspection was tasty and well presented in the dining room. The chef said that special diets could be prepared. One resident needed a special diet and confirmed that this was available to him. Residents had aids to help them eat as independently as possible. Carers were observed to be helping those service users who could not eat unaided in a discrete manner. The environmental health officer had recently visited the home and her recommendations had been received on the day of the inspection. The proprietors are drawing up an action plan to address these. The action plan should be shared with Commission for Social Care Inspection. Five Acres Nursing Home Version 1.10 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Although not all families are aware of the home’s complaints policies, they appear to work well when needed and give residents and their families the opportunity to raise issues, which can then be addressed. The protection of vulnerable people policies and procedures are in place and serve to protect residents from abuse. EVIDENCE: There is a complaints policy and a record is kept of complaints. The complaints recorded had been dealt with within the timescales set in the policy. There is a need to analyse complaints to identify and possible trends and to develop action plans to address these. Five of the six families who returned the comment cards however said that they were unaware of the homes complaints procedure although they had not had cause to complain. There is a need to ensure that everyone is aware of the complaints policies. Two family members were spoken to on the day of the inspection and one said that she had had a number of minor concerns when her mother moved to the home but that they were resolved promptly. There is a protection of vulnerable people policy and the home has copies of the Milton Keynes Multi-Agency Strategy to protect vulnerable adults. The staff spoken to had had training and were aware of the various types of abuse that may be suffered by vulnerable people. The home has two staff members who have undertaken a recognised course to train staff in the protection of vulnerable people. Five Acres Nursing Home Version 1.10 Page 16 Information regarding Age Concern’s advocacy services is available in the home. Five Acres Nursing Home Version 1.10 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 24, 25 and 26 Overall the standard of the accommodation has improved over the last year, following a refurbishment programme and investment by the new proprietors, and now provides residents with a comfortable, clean home in which to live. The control of infection policies and procedures have improved although some actions are needed to ensure that residents are fully protected from the risk of acquired infection. EVIDENCE: The home is an older building with a recent addition. The new proprietors and manager have made significant improvements to the environment. There is a redecoration programme and the lounges and communal areas have been redecorated and new curtains bought. Many of the chairs have been replaced. The gardens are mature and attractive and a new safe area has been fenced for residents who may wander. There are no CCTV cameras. There are two lounges and a dining room, which are attractive and welcoming. The lighting is domestic in character. Some resident’s rooms have been redecorated. Most are carpeted. Residents may personalise their rooms and Five Acres Nursing Home Version 1.10 Page 18 some have done so. There are a number of height adjustable beds for those residents who require nursing care. There is a need to replace all divan beds with height adjustable beds over a period of time and the proprietor has a plan to do this.. Preferably these beds should be domestic in character. The rooms are individually and naturally ventilated. Many of the windows have been replaced with double glazed units. The windows on the upper floor have window restrictors. The radiators are protected. Thermostatically controlled valves have been fitted to all water outlets. The home has new emergency lighting. The infection control policies and procedures have been improved since the last inspection. All residents now have liquid soap and paper towels in their rooms. The clinical waste is collected weekly although the bin was unlocked on the day of the inspection and is rather unsightly as residents and their families approach the home. One resident’s family has complained to the home about the catheter care. The proprietor and manager have meet with the family and new protocols implemented. It is recommended that the policies and procedures regarding catheter care are reviewed and updated. There is a sluicing facility. There is a separate laundry and new washing machines have been purchased in the last year. Soiled laundry is washed appropriately. The laundry floor is impermeable but is uneven and the surface is beginning to wear. It should be resurfaced as part of the general refurbishment programme before the surface becomes permeable. Five Acres Nursing Home Version 1.10 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 Overall the homes staffing levels and skill mix are sufficient to meet resident’s needs. The staffing levels at the weekend must be monitored to ensure that resident’s needs are always met. The home’s current recruitment policies and procedures work well and serve to protect residents from unsuitable care staff. There is an active training programme although the National Vocational Qualification programme will need to be increased if the home is to meet the required standard by the end of the year 2005 and for to staff have the formal skills and knowledge required to meet resident’s needs. EVIDENCE: There is a staff rota. The number of permanent staff have increased since the last inspection and a new qualified nurse is to start shortly. The staffing levels are enhanced during the mornings. The family members who returned the questionnaire said that they felt that there were always sufficient staff on duty although one visitor told the inspector that the staffing levels were reduced at the weekend. This was evident on the rota and the manager confirmed that staff are sometimes sick at the weekend. This must be monitored carefully and the staffing levels increased if there is evidence that resident’s needs are not met at the weekend. All staff are over eighteen and nobody under twentyone is left in charge of the home. In addition to the care team, there is a domestic team, chef and assistant, and a laundress. A part-time handyman is employed. Garden maintenance is contracted out. There is a National Vocational Qualification (NVQ) programme in place. One member of the care team has obtained The National Vocational Qualification in Five Acres Nursing Home Version 1.10 Page 20 Care at Level 2. Five carers are undertaking this course at Level 2 or 3. The manager is a qualified assessor and another member is undertaking this course. The home will need to focus on this programme if it is to meet the required standard by the end of 2005. The staff spoken to said that they had had opportunities for further training. Training records are kept. There is a need to ensure that night staff are included in the training programme and that all staff have dementia care training. Five staff recruitment records were examined in detail. All staff members recruited since the appointment of the new manager had the required documents and had a Criminal Records Bureau and Protection of Vulnerable Adults check. One staff member recruited before the new manager started did not have references. There is a need to ensure that all staff have an annual appraisal and that appraisal records are kept for staff who may have been in post for some years and did not have references taken up on appointment. Five Acres Nursing Home Version 1.10 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 36 and 38 The management arrangements in the home are satisfactory and residents are benefiting from investment in the facilities and the appointment of a new staff team. The quality assurance system must be improved to ensure that all the home’s processes are audited regularly and residents views are sought to give them the opportunity to influence the way in the home is run and their own care. Resident’s personal allowance is managed well, protecting them from financial loss. Overall the health and safety policy and procedures are satisfactory but would be enhanced by a thorough audit against the guidance published by the Health and Safety Executive to ensure that there is no potential for residents or staff to be put at risk by failures in safety measures. EVIDENCE: The newly appointed manager has nursing experience in an acute hospital setting and in the care of the elderly. She is currently undertaking the National Vocational Qualification in Management at Level 4. She is responsible Five Acres Nursing Home Version 1.10 Page 22 for one establishment. She has applied for registration with the Commission for Social Care Inspection. There are clear lines of accountability within the organisation and the respective roles and responsibilities of the manager and the proprietors. The organisation has an operational plan for Five Acres, which is set in the context of the group as a whole. The proprietors state that they are working towards Investors in People accreditation in all their homes. The home does not yet have a systematic quality assurance scheme in place. The proprietor said that they have a copy of the Registered Nursing Home’s Blue Cross Quality Assurance scheme but have not yet decided whether to implement this in full. There is a need to agree the approach and to implement an objective quality assurance system, which includes regular audit of all the home’s processes and seeks to ascertain the view’s of residents and their families on a regular basis. The notice of this planned inspection was posted in the entrance hall. The requirements of previous reports have been addressed although some work is still in progress. The financial procedures are managed from the head office. The proprietors stated that the home was financially viable. Appropriate insurances are in place and the insurance certificates are on display. The financial plan was not seen on this occasion. The home manages the personal allowance for some residents. Records are kept of all transactions and receipts are given. The registered manager is not an appointee for any resident. A key worker system has been implemented and the manager said that the qualified nurses now supervise a team of carers. Formal supervision has not yet been introduced although there are plans to do so over the next year. There is a Health and Safety policy and procedures. Staff have had training in manual handling. The fire safety officer visited the home on the 17th January 2005 and made a number of requirements regarding fire safety. The fire doors have been adjusted, fire training has been implemented, overhead door closures have been purchased and a new fire alarm system installed. The staff spoken to understood the fire evacuation procedure. Seven members of staff hold first aid certificates, sufficient for a first aider to be on duty at all times. The maintenance records were up to date. The home has had a Legionella assessment. Undertaking a systematic audit against the criteria described by the Health and Safety Executive in their booklet Health and Safety in Care Homes would enhance the overall approach to Health and Safety. Five Acres Nursing Home Version 1.10 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 x x x 3 3 2 STAFFING Standard No Score 27 2 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 2 3 3 1 x 2 Five Acres Nursing Home Version 1.10 Page 24 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 7 Regulation 15 Requirement The proprietors and the manager should use the guidance of the Alzeimers Society to develop specialist care plans to meet the needs of the residents who have dementia. The proprietors and manager should ensure that residents and their families involvement in the care plans is documented. Entries to the care plan should be made contemporaneously and dated and signed. This should include the night staff. Residents who have a social service care management plan should have that plan reviewed annually. The menu should include five portions of friut or vegetables daily. An evening soft option should be described on menu. The proprietors should ensure that all families are aware of complaints procedure. The proprietors should agree a programme to provide height adjustable beds for all residents requiring nursing care over a period of time with the Version 1.10 Timescale for action 31.12.05 2. 7 12 31.12.05 3. 7 15 30.09.05 4. 7 15 31.12.05 5. 6. 7. 8. 15 15 16 24 16 16 22 23 30.09.05 30.09.05 30.09.05 30.09.05 Five Acres Nursing Home Page 25 9. 26 16 10. 26 13 11. 12. 13. 14. 26 33 36 38 16 24 18 13 15. 16. 38 4 13 18 Commission for Social Care Inspection The general and clinical waste bins should be stored discretely and the clinical waste bin should be locked. The manager should review the catheter care policies and pocedures taking the advice of the local infection control nurse. The laundry floor should be made level and impermeable The proprietors should agree and implement a systematic quality assurance programme. The manager should introduce a formal system of supervision. The proprietors and manager should undertake an audit of health and safety in the home against the criteria identified by the Health and Safety Executive and develop a plan to address any deficits. The requirements of environmental health officers report must be implemented. All staff should receive dementia care training. 31.12.05 30.09.05 31.03.06 31.12.05 31.12.05 31.12.05 30.09.05 31.12.05 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 Good Practice Recommendations Five Acres Nursing Home Version 1.10 Page 26 Commission for Social Care Inspection 8 Bell Business Park Smeaton Close Aylesbury Buckinghamshire HP19 8JR 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. 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