Inspection on 09/01/07 for Fore Dore Nursing Home Ltd

This inspection was carried out on 9th January 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 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

Fore Dore Nursing Home Ltd 07/10/08

Fore Dore Nursing Home Ltd 30/10/07

Fore Dore Nursing Home Ltd 26/06/07

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

CARE HOMES FOR OLDER PEOPLE Fore Dore Nursing Home Ltd Fore Dore Trebetherick Wadebridge Cornwall PL27 6SB Lead Inspector Alan Pitts Key Unannounced Inspection 9th January 2007 09:30 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 Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fore Dore Nursing Home Ltd Address Fore Dore Trebetherick Wadebridge Cornwall PL27 6SB 0208 6843559 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered provider (if applicable) Type of registration No. of places registered (if applicable) Fore Dore Nursing Home Ltd Sadasivan Jyothi Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service users to include up to 2 adults with a terminal illness (TI) Service users to include up to 32 adults of old age (OP) Service users to include one named resident outside of the agreed age range. 3 OP residential clients must reside on first floor rooms. Total number of service users not to exceed a maximum of 32. Date of last inspection 20/05/06 Brief Description of the Service: Fore Dore is a detached property situated within a rural village location, surrounded by countryside. The nearest main town is Wadebridge. Fore Dore provides accommodation and nursing care for up to 32 people in need of care due to old age, physical disability or terminal illness. The accommodation is on two floors, with the upper floor being accessed by a stair lift/narrow stairs. The upper floor accommodation is for more able, non-nursing residents. Fore Dore has several long corridors and wings, which give the feel of separate units. Most areas of the home are accessible by sloping corridors to facilitate differing levels of the floor. Service users have a choice of 4 sitting rooms and a dining area as communal space. There is an outdoor seating area to the front of the property. There is also a car park at the front of the home. A trained nurse is on duty over the 24-hour period. There is a registered provider in post. The range of fees charged was not ascertained at this inspection in the absence of the registered provider and registered manager. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place on the 9th January 2007 over a period of approximately 5.5 hours, and was carried out by Mr Alan Pitts and Mr Mike Dennis. The inspection included examination of documentation, discussion with five staff, six residents, and a tour of the premises. Responses from residents were positive, and the staff are to be commended for their hard work and commitment in difficult circumstances. The registered manager is currently absent due to illness, and the registered provider is not in day-to-day control resulting in an evident lack of leadership and a low staff moral. Effective management is a priority for this home. Overall, the inspectors consider that the home provides a poor level of service to residents, primarily due to inadequate staffing levels and a lack of effective management. What the service does well: What has improved since the last inspection? What they could do better: Whilst outcomes for residents are perceived by them to be good, staff moral is low and staff said they were tired. The home lacks clear leadership and management in the absence of the registered manager. It is hoped that the registered manager will return to work in the near future, but in the meantime the registered provider must strengthen managerial arrangements at the home. The home is currently working on a day-to-day basis. The registered Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 6 provider must do more to show that investment in staff is as important as investment in the fabric of the building. The registered provider must increase the numbers of care staff on duty. 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. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 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 Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. National Minimum Standards 3, and 6 were inspected. This judgement has been made using available evidence including a visit to this service. Prospective residents’ care needs are assessed prior to admission, though this could be improved. A more proactive approach would better serve residents. The home does not provide intermediate care. EVIDENCE: The care files for the most recent admissions to the home were inspected and these showed that pre-admission assessment information had been obtained. However, the nurse in charge confirmed that this was achieved by virtue of the referring authority faxing the information, rather than a suitable trained member of staff from Fore Dore carrying out the assessment, meeting the residents, and forming their own judgement as to the home’s ability to effectively meet the care needs of the resident. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 9 The registered provider should ensure that, where possible, assessments are carried out by the home, rather than relying on information provided by others. The home does not provide intermediate care. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. National Minimum Standards 7, 8, 9, and 10 were inspected. This judgement has been made using available evidence including a visit to this service. Residents care needs are set out and provided for in individual care plans for the majority of residents, but not always and this can lead to an inconsistency in care delivery. The care documentation and comments from residents support the assertion that care needs are met, but this is fragile as demonstrated by the prolonged administration of medicines and comments made in other parts of this report. The home operates relevant policies and procedures for dealing with service user’s medicines, but the day-to-day pressures on staff may result in nonadherence to these presenting potential risks to residents. Residents were complimentary of the staff and their kindness and courtesy, confirming that they felt they were respected and their right to privacy upheld. EVIDENCE: Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 11 Four resident care files were inspected, one of which did not contain a care plan. This resident had been admitted 5 days previously, and whilst it is recognised that this was a respite placement, there should nevertheless have been a care plan in place. The registered provider must ensure that there is a care plan for each resident. One resident’s file showed no evidence of the care plan having been reviewed. None of the care plans showed evidence of having been reviewed with the involvement of the resident or their representative. One resident confirmed that they are not involved in this process. Care plans were otherwise observed to be informative, and the remainder of those inspected were reviewed regularly by the staff. The home could do more to keep residents informed in this respect. The registered provider should ensure that care plans are reviewed with the involvement of the resident or their representative, where possible. The care plans and supporting documentation showed that residents’ care needs are recognised, and that the residents have access to health care professionals as appropriate. The care documentation shows that a number of assessment tools are used at the home, including risk of falls, and nutritional assessments. A GP was visiting at the time of the inspection, though unfortunately was too busy to pass comment on the home. Receipts also show attendance by visiting practitioners, such as chiropodists. There is a medication procedure in operation at the home. Medicines were seen to be stored appropriately and securely. Medicine Administration Records were seen to be in order, as was the Control Drug book. There is a record of staff competency with medication and a reference list of staff signatures. Staff were observed to be very busy, the nurse rostered to be in charge was a bank nurse, and it was their first shift unsupervised. The nurse who accompanied and assisted the inspectors said that she was rostered for managerial duties. There was four care staff on duty. The dependency of some of the residents, and the arrival of a GP to review his patients was sufficient to disrupt the morning medication round. The morning medications were still being administered at 11.10am, and there was no discernible break between the morning and lunchtime medication administration. It is not possible to say that residents’ care needs are met, for the reasons expressed above. This matter is also discussed later in the report under staffing, and the registered provider must ensure that residents are protected by the safe and timely administration of medicines at all times. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 12 Service users confirmed that staff administer the medications and did not express any concerns. Residents were complimentary about the staff, their kindness, and their commitment to their welfare. The residents confirmed that they felt respected and their right to privacy was upheld. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. National Minimum Standards 12, 13, 14, and 15 were inspected. This judgement has been made using available evidence including a visit to this service. Two residents commented that there is a lack of stimulation at the home, and the care documentation supports the assertion that the home could do a lot more to ensure that the lifestyle experience of residents matches their expectations. There is a reasonable amount of choice available to residents on a daily basis, and residents are able to maintain contact with family and friends. On the whole the diet is appetising, balanced, and well presented, but this is not true for those requiring soft diets. Assistance with meals was not timely. EVIDENCE: There is a monthly activity plan, but the activity records have only minimal entries in the care documentation to indicate any kind of lifestyle, most of the five inspected were blank. Two residents commented that there is a lack of stimulation, and the nurse in charge was not able to provide any information Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 14 about organised activities. The nurse in charge did not demonstrate an understanding of the importance of social/recreational activities to residents. Staff were observed to be very busy throughout the course of the inspection and reference has already been made to medicines not being administered on time. It is the opinion of the inspectors that the current staffing levels are not sufficient to meet the basic care needs of the residents, and are therefore certainly insufficient to meet any social/recreational needs. The registered provider must make arrangements to enable residents to engage in local, social, and community activities. There is a visitor’s book at the entrance to the home, though this was full and a new book or new pages was needed. The care documentation was informative and recorded when residents received visitors. The residents spoken with confirmed that they were free to receive visitors without restriction. Residents confirmed that they are able to determine their own waking day, and also that a choice is offered at meals. Further options for choice, such as in daily lifestyle, are limited as there is insufficient staff available to facilitate this. There is a weekly menu, and a record of the food provided is kept. The cook ensures that each resident is asked on a daily basis what their choice is for meals the following day. Meat is delivered weekly, and fresh local vegetables are delivered three times a week. On the day of the inspection the lunchtime menu offered a choice between fishcakes or pasties, the latter being on the menu at the request of a resident who was leaving that day. The lunch meal was seen to be well presented and in sufficient amounts. However, similar care and attention is not given to soft diets. Soft diets are prepared correctly (individual components being processed and served individually), but are not delivered to the resident appropriately. Staff assisting residents with their meals were seen to mix the individual components of the meal into ’porridge’. This is poor practice, and assumes that the resident has no sense of taste, nor does it respect the resident’s dignity. Residents in need of assistance at meals were also seen left with a meal on the table in front of them for 10-15 minutes. This means that the meal grows cold before the resident gets to eat it. Again this was due to the number of residents needing assistance, the number of staff available to do so, and comment is made about staffing levels later in this report. The registered provider must ensure that the serving and presentation of meals is done to a high standard for all residents, and in a timely manner to ensure optimum temperature. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. National Minimum Standards 16, and 18 were inspected This judgement has been made using available evidence including a visit to this service. Residents were confident that they would be listened to, though the nurse in charge was not aware of a complaints policy. Residents are protected by an ‘abuse’ policy, but the nurse in charge was not familiar with the procedure to be followed in the event of an allegation. Residents are not sufficiently protected. EVIDENCE: This is the first key inspection since the registered provider purchased the home. The Commission for Social Care Inspection have not investigated any formal complaints in that time, but there has been contact with the home in respect of concerns expressed by staff at the home. Residents spoken with confirmed that the staff are considerate and kind, and that they would feel able to express any concerns they may have. The nurse in charge was aware that there was a form for recording complaints, but did not know of a complaints procedure. The complaints procedure was not seen on display anywhere in the home. The previous inspection in May 2006 identified that the complaints procedure had not been provided to residents or their representatives. The registered provider should ensure that the staff, residents, and their representatives have the necessary information and understand how to make a complaint and how to manage a complaint. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 16 There is policy and guidance documentation relating to the Protection Of Vulnerable Adults, but this does not provide clear instruction to staff as to the steps to be taken. The nurse in charge did not demonstrate a clear understanding of the steps to be taken in the event of an allegation of abuse. The registered provider must introduce a POVA procedure, which provides clear instruction to staff regarding the steps to be taken in the event of an allegation of abuse, and the necessary contact details of the relevant agencies. The registered provider must ensure that all staff are aware of and understand the home’s adult protection procedure. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. National Minimum Standards 19, and 26 were inspected. This judgement has been made using available evidence including a visit to this service. Residents live in an environment that is benefiting from the investment being made by the registered provider into the furniture and fittings. However, this investment does not include sufficient cleaning and infection control measures. EVIDENCE: The home offers 32 single rooms, 30 of which are en-suite. There are three communal lavatories, one of which is in a bathroom. There are three bathrooms and a shower room. There are toilets situated near to the communal facilities. The registered provider has invested significant amounts of money in improvements to the premises: • replacing the communal carpets throughout Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 18 • • • replacing the carpets in empty rooms provision of ramps in communal dining and lounge areas provision of new dining and lounge furniture Service user rooms are pleasant with personal items evident, including in some cases, personal telephones and other equipment. Heating, lighting, and hot water supply was noted to be in working order. The home was reasonably clean in appearance, but further inspection revealed that high cleaning was not being carried out. One sluice room was ‘out of use’, though the nurse in charge did not know why. An overfull clinical waste bin, the smell from which was overpowering, blocked access to the sluice machine in the other sluice room. There is one full-time equivalent cleaner employed at the home. The laundry is away from the food preparation area and has industrial type machines. Service users’ washing is sorted into individual boxes to be taken to rooms. Three full sacks of dirty laundry were seen on the floor of the laundry. There is one full-time laundry person employed at the home. The laundry person was not on duty in the morning of the inspection, but was rostered for duty later that day. The incomplete cleaning of the premises, the delayed emptying of clinical waste bins, and the delayed management of dirty laundry poses a threat to the welfare of residents and staff. Comments are made later in this report in respect of staffing levels. The registered provider must ensure that the home is kept clean, that arrangements are in place to prevent the spread of infection, and that arrangements are in place for the disposal of general and clinical waste. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. National Minimum Standards 27, 28, 29, and 30 were inspected. This judgement has been made using available evidence including a visit to this service. There is insufficient staff to meet the needs of the residents and to protect their health and well being. It was not possible to establish whether the levels of staff skills and training protect residents, nor whether the recruitment policy operated by the home protects residents, as the relevant records were not available for inspection. EVIDENCE: Staff were observed and heard to be frustrated and unhappy about the workload and their ability to meet the care needs of the residents. Staff spoken to expressed concerns about the numbers of staff on duty and the high dependency of the residents. At the time of the inspection there were 23 residents living at Fore Dore, with 5 care staff (one nurse) rostered for duty to meet their care needs. The nurse in charge told the inspectors that she was rostered for administrative duties in the office, and openly questioned the appropriateness of the current staffing levels. The inspector advised the nurse of their responsibilities in respect of their registration with the Nursing and Midwifery Council. The staff and the duty rota also confirmed that some staff are working long shifts (e.g. nurse in charge: 9am-1pm in the office, 2pm-9pm caring). The care documentation confirmed the high dependency of most of the Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 20 residents, and the nurse in charge stated that approximately 50 of the residents were hoist dependent. Comments made earlier in this report indicate that medicines are not being administered safely, that there are no arrangements for the social/recreational lifestyle of residents, and that residents who need assistance with meals are left waiting for this, and that laundry and cleaning arrangements are insufficient. The comments of the staff also indicated low moral, due to staffing levels, “erratic pay dates”, and the “poor attitude” of the registered provider. Residents’ comments support the hard work of the staff, but are also observant of how busy they [the staff] are. There was some comment from residents about not always being able to understand the staff. The staff the inspectors met had a good command of the English language, but any deficit either on the part of the speaker or the resident would be exacerbated if staff are rushed in their duties. The registered provider must increase staffing levels to ensure that the care needs of residents are met, and the home is kept clean and hygienic. There was some evidence of staff training certificates in respect of manual handling, and there was a training overview, which indicated that nine out of fifteen care staff have achieved NVQ Level 2 training or above. There were no current staff training records available for inspection, including evidence of National Training Organisation compliant induction training. The inspectors were therefore unable to ascertain the levels of staff training and the competence of the staff at the home. The nurse in charge did not have access to the filing cabinet containing the staff personnel files, and these files were not available for inspection. The registered provider must ensure that all required records are available for inspection at all times. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. National Minimum Standards 31, 33, 35, and 38 were inspected. This judgement has been made using available evidence including a visit to this service. There is a registered manager at Fore Dore, but he is currently absent due to sickness and residents are not benefiting from effective management and leadership during this absence. There is some evidence of quality assurance at the home, but insufficient to say that the home is committed to this. It was not possible to ascertain whether residents’ financial interests are safeguarded. Similarly, it is not possible to confidently state that the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The registered manager is currently absent due to sickness. The registered provider has designated a person to act as manager during this period, though Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 22 more information is needed by the Commission for Social Care Inspection (please refer to the enclosed improvement plan for details). The staff commented on the home being “chaotic”. The registered provider has not made effective arrangements for the ongoing management of the home in the registered manager’s absence. The registered provider must advise the Commission for Social Care Inspection of the arrangements for the continuing management of the home in the absence of the registered manager. The inspector saw a sample of returned quality assurance questionnaires, but there is no evidence of the home continuing with this process (making a summary of the findings available to residents/representatives) or of any action taken by the home in response to the comments received. The registered provider should continue with the quality assurance questionnaires, publishing a summary of the findings and any action taken as a result of the responses. Records relating to residents finances were not available for inspection. The registered provider must ensure that all required records are available for inspection at all times. There is a lack of evidence of effective management at this home (e.g. staff numbers, employment, staff training and induction). Effective management is necessary to ensure the health, safety and welfare of the residents and staff. The maintenance records inspected and found to be satisfactory are: • IEE test • Accident reports • Waste contract • Boiler maintenance • Hoist maintenance • Fire safety/equipment maintenance Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 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. 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 1 X X 2 Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP9 Regulation 15 13 Requirement The registered provider must ensure that there is a care plan for each resident. The registered provider must ensure that residents are protected by the safe and timely administration of medicines at all times. The registered provider must make arrangements to enable residents to engage in local, social, and community activities. The registered provider must ensure that the serving and presentation of meals is done to a high standard for all residents, and in a timely manner to ensure optimum temperature. The registered provider must introduce a POVA procedure, which provides clear instruction to staff regarding the steps to be taken in the event of an allegation of abuse, and the necessary contact details of the relevant agencies. The registered provider must ensure that all staff are aware of and understand the home’s adult DS0000066667.V310469.R02.S.doc Timescale for action 01/02/07 01/02/07 3. OP12 16 01/03/07 4. OP15 16 01/02/07 5. OP18 13 01/03/07 Fore Dore Nursing Home Ltd Version 5.2 Page 25 6. OP26 13, 16 7. OP27 18 8. OP29 OP30 OP35 OP31 17 9. 39 protection procedure. The registered provider must ensure that the home is kept clean, that arrangements are in place to prevent the spread of infection, and that arrangements are in place for the disposal of general and clinical waste. The registered provider must increase staffing levels to ensure that the care needs of residents are met, and the home is kept clean and hygienic. The registered provider must ensure that all required records are available for inspection at all times. The registered provider must advise the Commission for Social Care Inspection of the arrangements for the continuing management of the home in the absence of the registered manager. 01/02/07 01/02/07 01/02/07 01/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP7 OP16 Good Practice Recommendations The registered provider should ensure that, where possible, assessments are carried out by the home, rather than relying on information provided by others. The registered provider should ensure that care plans are reviewed with the involvement of the resident or their representative, where possible. The registered provider should ensure that the staff, residents, and their representatives have the necessary information and understand how to make a complaint and how to manage a complaint. The registered provider should continue with the quality assurance questionnaires, publishing a summary of the DS0000066667.V310469.R02.S.doc Version 5.2 Page 26 4. OP33 Fore Dore Nursing Home Ltd findings and any action taken as a result of the responses. Fore Dore Nursing Home Ltd DS0000066667.V310469.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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. 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