Inspection on 04/10/07 for Fountain Nursing Home

This inspection was carried out on 4th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Fountain Nursing Home 11-17 Fountain Road Edgbaston Birmingham B17 8NJ Lead Inspector Lisa Evitts Unannounced Inspection 4th October 2007 09:05 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 Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fountain Nursing Home Address 11-17 Fountain Road Edgbaston Birmingham B17 8NJ 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) 0121 429 6559 0121 434 3116 None None Fountain Nursing & Care Ltd Mrs Lauret Fiellateau Care Home 27 Category(ies) of Dementia (27), Old age, not falling within any registration, with number other category (27) of places Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (with nursing) and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 27 Dementia (55 years and over) (DE) 27 The maximum number of service users to be accommodated is 27. 2. Date of last inspection New Service Brief Description of the Service: The Fountain Nursing Home is a large converted detached property, which is registered to provide nursing care for twenty-seven people who may also have dementia care needs. The home has been established for a number of years but has new owners since June 2007. The home is situated relatively close to Birmingham town centre and is within easy reach of public transport facilities. There is a large, enclosed garden to the rear and limited off road parking to the front of the property. Accommodation is provided in 11 single bedrooms and eight double rooms with some having en-suite facilities. Communal accommodation consists of three separate lounges, a dining room, porch and a visitor’s room. The home has hoisting equipment and specialised mattresses for people who may develop sore skin. People who use wheelchairs can access the building as a ramp is provided to the front and back entrance and a passenger lift enables people to reach all floors of the home. The home has five toilets, two bathrooms and two showers in addition to ensuite facilities. One shower would require people to negotiate a small step however staff are available to assist as required. There is a notice board in the entrance of the home, which displays articles and information about forthcoming events, which may be of interest to people. Although the home has been established for some time, this is the first visit to the home under the management of the new owners and therefore no previous reports are available. Information about fee rates is available from the home but is not included in the statement of purpose. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The visit to the home was undertaken by one inspector over eight hours and was assisted throughout by the Registered Manager. The home did not know that we were visiting on that day. There were 26 residents living at the home on the day of the visit and one room was vacant. Information was gathered from speaking to five people who live at the home. Staff were observed performing their duties and two staff were spoken to. Three people were “case tracked” and this involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were also reviewed. Two resident questionnaires and one relative questionnaire were returned prior to the inspection, which provided us with peoples views of the home. Prior to the inspection the Registered Manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave good information about the home, staff and residents, improvements and plans for further improvements, which was taken into consideration. Regulation 37 reports pertaining to accidents and incidents in the home were also reviewed in the planning of the visit to the home. No immediate requirements were made on the day of the fieldwork visit. What the service does well: People are provided with information about the home so that they can make an informed decision about whether they would like to live there. Access to a range of external healthcare professionals is good and this ensures that all healthcare needs are met. The management of medication is good and this ensures that people receive their medication as prescribed. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 6 People are offered a choice of meals, which can meet any dietary, cultural needs or personal preferences. There is a friendly atmosphere at the home and people can personalise their own rooms to reflect preferences and tastes. A core group of staff is maintained so that people know who will be assisting then to meet their needs. People are encouraged to join in meetings so that they can voice their opinions about the home and activities. Maintenance checks are completed to ensure that equipment is in full working order and safe to use. People told us: “Its quite a good place to be” “I’m happy here” “I have no complaints about anything” “The food is quite nice, I’ve had choices” “We get someone come in and give us exercise” “I share a room but I’ve got my own things” “Staff couldn’t do anymore” What has improved since the last inspection? What they could do better: Some of the care plans sampled had good details about personal preferences and needs. Staff must ensure that this good practice is consistent across all files, so that information is available to meet people’s needs in a way that they like. Care plans should be written for short term needs so that staff can monitor progress. One reference must be obtained from prospective staff members last employers so that people are safeguarded. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 7 The quality assurance system needs to be further developed and an annual report, including an action plan with timescales, should be written so that the home makes continuous improvements to the service offered. 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. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available for prospective people and their representatives to make an informed decision about whether they would like to live at the home. Comprehensive pre admission assessments are undertaken so that people know that the home can meet their needs prior to moving in. EVIDENCE: The home has a very comprehensive statement of purpose, which was reviewed and updated in June 2007. A service user guide and brochure are also available and these provide people with information to help them make an informed decision about whether they may like to live at the home. The documents are available in large print upon request and this means that people who have visual impairments can also access the information. The home does not currently have a website or email access but is something they want to develop in the future. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 10 A copy of the Public Liability Insurance and Registration Certificate are on display in the reception area so that people can see these if they wish to. The manager informed us that people who live at the home will be issued with new contracts due to the home having new owners. This will ensure that people who live at the home know what their terms and conditions of residency are. A comprehensive pre admission assessment was seen on the file of a recently admitted person to the home and this ensures that the person requiring the service and the home know that their needs can be met prior to moving in. The home does not provide intermediate care facilities. People told us: “I’m happy here” “Its very good here” “Its quite a good place to be” Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples’ healthcare needs and personal choices are generally being met but this is not always evidenced in the care planning. The management of medication means that people receive their medication as prescribed. EVIDENCE: Each person has a written care plan. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for needs to be met. Three people files were reviewed. A background information sheet provided details about the persons past history and this gives staff an insight into the person’s life. This would give staff topics of interest to talk to people about which may help them feel more relaxed. One of these stated that the person had an allergy to a medication but on the admission chart it stated ‘no allergies’. Staff must ensure that information recorded is correct to prevent people from receiving a medicine that they may be allergic to. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 12 There was some evidence of personal preferences being recorded but this requires further work so that people receive care in a way that they like and that meets their needs. Examples of this were “likes to go to bed at 4pm” and “requires a plate gripper”. One persons care plan said to have a bath twice weekly but the evaluation suggested that assisted showers were given, and this does not ensure that peoples personal preferences are being taken into consideration. There was evidence that the people living at the home and their families were involved in the care plans. One person had been treated for an infection but no short-term care plan had been formulated and these are required so that their needs can be monitored. There were no incidents of people with sore skin in the home at the time of the visit and waterlow scores (a tool for measuring the risk of skin sores developing) are monitored and recorded monthly. Not all of the plans detailed the type of cushions or mattresses that people needed to minimise the risk of sores developing, even though this equipment was in place. One person had a care plan for the risk of sore skin developing and this had been updated to reflect current care needs. One person said, “I want a new bed, I can’t sleep properly”. On discussion with the manager the person had been put onto a special mattress due to being at risk of sore skin. The manager agreed to discuss this again to find a solution while maintaining the needs of the person and preventing their skin from breaking down. Manual handling assessments had been completed but did not give specific details of the hoist and sling size to be used, so that the identified equipment was used to assist people. One person was fed through a tube but details of how to care for the site and the tube had not been entered on the care plan so that staff knew what to do. There were good details of likes and dislikes in regards to food and this should ensure that people receive food that they like. Nutritional scores are recorded and weights are monitored each month. This should ensure that staff refer people to other healthcare professionals as required. External healthcare professionals such as the chiropodist, optician, General Practitioner, social worker, and tissue viability nurse had seen people and this ensures that they receive specialist advice. People who move into the home can stay with their GP (If they are in agreement) or they can be registered with a local GP. The management of medication was reviewed and was generally well managed which means that people receive their medication as it is prescribed. Audits were completed on four peoples Medication Administration Charts (MAR) and balances were found to be correct with the exception of a boxed pain relief. It Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 13 was not clear from the records how many had been administered and it was not possible to follow an audit trail. Eye drops and insulin were dated when opened and this means that they would be replaced as required therefore minimising the risk of infection. Fridge temperatures were monitored daily to ensure that medications were stored at the correct temperature. Controlled medications were securely stored and balances were correct. Copies of prescriptions are kept so that staff can check that the correct medication is received into the home. The manager completes a monthly drug audit and a weekly staff compliance audit so that any discrepancies can be rectified. The home has a pay phone which people can use if they choose to make calls. This is located in a quiet area of the home but may not afford privacy to people using it. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are able to exercise their choice over their daily lives and the activities they choose to participate in which promotes independence and individuality. Trips outside of the home would enhance the lives of some people who live at the home. People receive a varied diet, which meets any specific dietary, cultural needs or preferences. EVIDENCE: The home does not have a dedicated activities coordinator and staff assist residents with activities. There are a variety of in house activities on offer including, games, arts and crafts, gardening, flower arranging and computer lessons. Four people have their own choice of newspapers delivered and the library visits so that people can choose books, which interest them. A monthly entertainer is provided and exercises to music for those who wish to join in. Bingo and a film night are held once a week. People are supported to continue with their religious beliefs, two local churches visit the home and the Roman catholic priest visits to give Holy Communion to those who wish to receive it. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 15 One person said “We get someone come in and give us exercises, whoever wants to can join in”. Staff encourage people to maintain links with the local community and two residents go out to church on a Sunday. People are encouraged to go out with their relatives and one person enjoys shopping with the staff. The home has built up a good rapport with the local school and three people who live at the home had recently attended their open day. There have not been any day trips outside of the home arranged at present. One person said that they would like to go out more often “Just a bit each day for some fresh air”. This was discussed with the manager at the time of the visit. The home has a cat and this may be of particular interest to people who have owned cats or other animals in the past. There are photographs displayed in the home of past activities, which people have enjoyed. The home has an open visiting policy, which means that people who live at the home can see their visitors as they choose. We observed the lunch meal and staff were seen to assist residents appropriately while maintaining their dignity. Tables were set with cloths; cutlery and cold drinks were available with the meal. The choice of meal was gammon or fish with parsley sauce and boiled potatoes and vegetables. Staff were asking people what they would like. The sweet consisted of yoghurt or egg custard. One person asked for fruit as an alternative and this was arranged. The home has a four-week menu; cooked breakfasts are available on the weekends with toast, cereals and porridge. There are two choices of hot meals at lunchtime and a hot or cold choice in the evening. People told us: “The food is quite nice, I’ve had choices” “Food has changed for the better, we can eat it now” “Food is not too bad, sometimes we get Caribbean” “I had a nice dinner today” Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, which is accessible to people who live at the home and their representatives if they need to make a complaint. There are systems in place that should protect people from harm. EVIDENCE: There is a comprehensive complaints procedure on display in the reception of the home. This is available in large print to assist people with visual impairments to access the information and is included in the statement of purpose. The home had not received any complaints since the new providers had purchased the home. We have not received any complaints or concerns about the home. There are a number of thank you cards and letters on display, which suggests satisfaction with the service provided. A suggestion box has been implemented so that people can voice their opinions on any aspect of the home. One person spoken to said, “I’ve no complaints about anything”. One person told us that they would like to go out more and another that they would like a new bed. This was discussed with the manager at the time of the visit and she was already aware of these requests and was working towards resolving them. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 17 The home has a copy of the Birmingham Multi Agency guidelines and an adult protection policy, which gives staff guidelines to follow, should there be an allegation of abuse. We spoke to staff and they were able to tell us what action they would take if an allegation of abuse was made and this should ensure that people are safeguarded from harm. Some staff have received training in the Protection Of Vulnerable Adults but not all. It is recommended that all staff receive training in this to ensure that they have the knowledge to safeguard the people who live at the home from harm. The home has a whistle blowing policy in place so that staff can raise concerns without the fear of reprisals. It is recommended that the missing persons policy is amended to include informing the person’s social worker and the completion of a well person check on return to the home. An inspector from another area had visited the home earlier in the year and the home had been very co operative in providing the information required. The staff however did not ask for any identification and this was brought to the attention of the manager. During this visit, we were asked to wait while the staff informed the manager of our arrival. Identification was only asked for when the staff member came back and this does not ensure the safety of the people living at the home. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with a clean and comfortable environment, where they appeared relaxed. Aids and adaptations meet the needs of people who live there. EVIDENCE: Access to the building is via a bell and this should mean that staff are aware who is in the building, providing that they check identification of callers to the home. Both the front and back entrances have ramps so that people in wheelchairs can access the building. A partial tour of the home was undertaken. Areas reviewed were those relevant to the three people who were case tracked. There was a pleasant atmosphere during the visit and the home was clean and odour free. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 19 The home has three lounges, separate dining room, porch and a visitor’s room. This means that people have alternative rooms to use if they do not want to stay in their bedrooms. The manager confirmed that since the new owners had taken over, all of the lounges had had new carpets laid and a number of bedrooms had been redecorated. Lots of new pictures had been put up around the home to make it an inviting place to live. The carpet on the first floor could be a potential trip hazard as was not completely secure and it is recommended that this is replaced to prevent the risk of injury occurring. The home has eleven single bedrooms and eight double rooms with some having en-suite facilities. A passenger lift provides people with access to all floors of the home. People had personalised their own rooms with furniture, ornaments and pictures to make their surroundings as comfortable and familiar as possible. All rooms have a lockable facility so that people can store items securely to maintain their privacy. Doors have locks, which have master keys so that staff can override them in the event of an emergency and two people had chosen to have keys to their rooms. Shared rooms have dividing curtains to maintain the privacy of the people using the room. There are two assisted bathrooms and two shower rooms. One shower would require the person to negotiate a small step however staff are available to provide assistance if required. It is recommended that this information is included in the statement of purpose. People were seen to be using equipment as required, for example cushions and specialised mattresses to reduce pressure and minimise the potential for sore skin developing. The home also has hoisting equipment to assist people with decreased mobility. It was noted that the COSHH cupboard (Control Of Substances Hazardous to Health) had been left open and this was brought to the attention of the manager who rectified this immediately. Staff should ensure that this is locked at all times to prevent people from accidentally coming into contact with the products, which may be harmful. People told us: “My bedroom is quite nice, its cool in there and I like it” “There have been lots of changes, new carpets put down and that’s good” “My bedroom had a new carpet and I’ve got my own fridge” “I share a room but I’ve got my own things” Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported by adequate numbers of staff, who receive some training, to ensure they have the knowledge to perform competently in their roles. Lapses in recruitment procedures may not ensure the safety of people. EVIDENCE: The home has two qualified nurses and five care staff on duty throughout the day and one trained nurse and two care staff during the night. The manager has some supernumery hours and the home was fully staffed with no current vacancies. The home generally maintains a core group of staff, which means that the people who live at the home know who will be assisting them to meet their needs. In addition to care staff the home also has domestic, kitchen and maintenance staff to meet all the needs of the people who live there. There are no male members of care staff working at the home, and the manager stated that this was something that would be taken into consideration in the future, although no one had raised any concerns about this. Some people may prefer to have a carer of the same gender. 100 of staff have completed National Vocational Qualification (NVQ) Level 2 and some staff have also achieved NVQ level 3. This should ensure that staff have the knowledge and skills to care for people individually and collectively. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 21 People told us: “Staff are quite nice” “Staff are not bad” “Staff are very good” “Staff couldn’t do anymore” “Staff are ok” Two staff files were reviewed and these did not have a reference from the last employer and this is required to safeguard people. Both files had Criminal Records Bureau checks in place and POVA first (Protection Of Vulnerable Adults) to safeguard people from harm. Neither of the staff had signed contracts in place and this is recommended so that staff know what is expected of them. Staff receive training and a training matrix is in place to assist in the monitoring of this and to identify when further training is required. The matrix showed that staff had had training in first aid, adult abuse, health and safety, dementia, diabetes, fire, infection control, end of life, manual handling and two qualified staff had completed a three day tissue viability course. The manager should ensure that all staff receive training in adult abuse as detailed in the complaints and protection section of this report. The home is currently taking part in “End of life” training with the Primary Care Trust. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally run in the best interests of the people who live there. Maintenance checks of equipment ensure a safe environment for people to live in. EVIDENCE: The Registered Manager has many years experience within care of older people and management, she has completed the Registered Managers Award, which will assist her knowledge in supporting and leading the staff team. Staff told us that they were pleased with the new providers and said, “once we see something, they get it fixed” and “whatever you ask for they do”. It was clear that staff had built up good relationships with the providers and were Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 23 working together to improve the home for the benefit of the people who live there. The providers support the manager and visit the home on a daily basis. Although the providers regularly visit the home, they are not in day-to-day charge of the home and are therefore required to undertake unannounced visits at least once a month and write a report as per Regulation 26. These reports should be available to the manager and for us to review when we visit. Prior to the inspection the Registered Manager had completed the Annual Quality Assurance Assessment (AQAA) and this gave us good information about the service provided, how it had improved and how it planned to improve further over the next year. This shows that the manager and providers have a clear vision of how the home could move forward. Residents and staff meetings are held and these give people the opportunity to share their ideas about the home, while providing a social activity. Minutes of these meetings were reviewed following the visit and were detailed. It appeared from the minutes that actions are taken to try and resolve any concerns raised in the interests of the people living at the home. Quality questionnaires have been sent out to all relatives and the manager is awaiting return of these. The manager should also include views of external stakeholders and the people who use the service when reviewing the quality. While some feedback is being obtained the home must now work towards formalising this information into a quality assurance system and produce an annual report on its findings, including an action plan to address any areas where improvements could be made. The home does not keep any personal monies; all items are invoiced to the residents or those responsible for the reimbursement of the fees. Staff from the home shop for toiletries and invoices are issued accordingly. Maintenance records of equipment and utilities were reviewed and indicated that appropriate health and safety checks were maintained to ensure the safety of people living at the home. The fire alarm is tested weekly and staff attendance at fire training is documented. This should mean that staff have the knowledge to safeguard residents in the event of a fire. Accidents are recorded along with any action taken to prevent the same incident occurring again, and the home informs us of any accidents or incidents as per Regulation 37. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 3 Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP7 Regulation 15 Requirement Care plans must provide specific details for staff to assist people to meet needs. Care plans must be written for short term needs so that staff can monitor the effectiveness of the treatment. References must be obtained from the last employer to keep people safe. The responsible individual must visit the home at least once a month and write a report on the conduct of the home so that quality is monitored. A formal quality assurance system must be implemented to gain the views of people receiving and visiting the service. Timescale for action 30/11/07 2. 3. OP29 OP33 19 Sch 2 26 16/11/07 30/11/07 4. OP33 24 31/12/07 Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. Refer to Standard OP9 OP12 OP18 OP18 OP18 OP19 OP19 OP21 OP29 Good Practice Recommendations Staff should clearly record the amount of boxed medications given so that an accurate audit trail can be followed. People should be assisted to go outside of the home safely and as they choose. All staff should receive training to ensure they have the knowledge to protect people from harm. The missing person policy should be amended to ensure that staff know who to inform and what action to take to ensure safety. Staff should be aware of who is entering the building so that people are safe from harm. The carpet on the first floor should be made safe or replaced to minimise the risk of harm. Cleaning items which cause harm should be secure at all times to prevent accidents occurring. The small step to the shower should be described in the statement of purpose so that people know this information. Staff should have a contract of terms and conditions of employment so they know what is expected of them. Fountain Nursing Home DS0000069493.V345529.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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