Inspection on 03/11/05 for Frithwood Nursing Home, The

This inspection was carried out on 3rd November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Frithwood Nursing Home, The 31/07/06

Frithwood Nursing Home, The 27/06/05

Frithwood Nursing Home, The 29/09/04

Frithwood Nursing Home, The 06/04/04

Frithwood Nursing Home, The 25/09/03

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

CARE HOMES FOR OLDER PEOPLE Frithwood Nursing Home, The 21 Frithwood Avenue Northwood Middlesex HA6 3LY Lead Inspector Clare Henderson-Roe Unannounced Inspection 3rd November 2005 1.00 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 Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 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. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Frithwood Nursing Home, The Address 21 Frithwood Avenue Northwood Middlesex HA6 3LY 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) 01923 820 955 01923 842 684 MD Homes Carolyn Estabilla Care Home 20 Category(ies) of Physical disability (0), Physical disability over 65 registration, with number years of age (0), Terminally ill (0) of places Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Adults over 55 years old in need of general nursing care and Palliative Care Minimum Staffing Notice Date of last inspection 27th June 2005 Brief Description of the Service: Frithwood Nursing Home is a converted detached house situated in a residential area of Northwood. It has a well-maintained private garden at the rear of the property. The accommodation consists of fourteen single and three double rooms. There are three bathrooms, one shower room plus toilet facilities throughout the home. There is a day room and a dining room for service users to utilise. Local transport facilities are available in the form of buses and Northwood Underground Station. The Registered Manager deals with the care management for the home. The Operations Manager deals with the financial and personnel management of the four homes within MD Homes. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 12 hours was spent on the inspection process. The Inspector carried out a tour of the home, and inspected service user plans, staff records, financial records, maintenance and servicing records. 8 service users, 3 staff and 1 visitor were spoken with as part of the inspection process. The purpose of this inspection was to follow up the requirements and recommendations from the last inspection, and to view some additional standards. The majority of key standards were viewed at the last inspection and it is recommended that this report be read in conjunction with the last report to gain full inspection information for the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 6 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 Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 The pre-admission assessment process being used does not fully identify the suitability of placement, thus not ensuring that the home can meet the service users needs. Service users with specialist needs outside the homes categories of registration are accommodated at the home. This can impact on other service users and staff do not always have the skills to meet these needs. EVIDENCE: A pre-admission assessment is carried out for all prospective service users. The current process needs to be reviewed to ensure that any specialist care needs, to include dementia and mental health, are clearly identified at the time of assessment, to ensure that the home does not admit service users outside of, and therefore breaching, their categories of registration. On the first day of inspection one service user was very distressed and exhibited signs of paranoia. On viewing the records it was clear that they have a mental health diagnosis. Another service user with a diagnosis of dementia was shouting out whenever left unattended, and it was clear that this was impacting on other service users. The reaction of some of the staff indicated that they do not have the specialist skills and knowledge to manage these Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 8 service users appropriately. Some of the service users spoken with in the lounge had difficulty communicating and there was evidence of some levels of confusion, plus in some instances, a diagnosis of dementia. When asked, staff reported that some service users strike out at staff during personal care giving. Overall there was an atmosphere of anxiety on the first day of inspection. The home is not registered to accommodate service users with mental health or dementia care needs, and a full assessment of all service users must be carried out to identify service users with such diagnoses. Where service users behaviours are impacting on other service users, action to ensure that each service user is appropriately accommodated must be taken. Where service users with a diagnosis of dementia are not impacting on any other service users an application for variation to the homes conditions of registration can be made, to continue accommodating those service users whilst their behaviour has no impact on other service users. Ongoing dementia care training must be in put in place so that staff are up to date and competent in the care of service users with dementia. Once addressed, this situation must not be allowed to repeat itself. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 The service user plans are not always fully up to date, and thus do not provide staff with current information to meet the service users needs. Overall medications are well managed, although shortfalls identified could potentially put service users at risk. EVIDENCE: Service user plans were sampled as part of the inspection process. Some of the information contained therein was very general and specialist care needs were not always identified. For example, for a service user with mental health care needs the care plan did not clearly identify these needs. In other service user plans viewed the information was more comprehensive and personalised. Monthly updates had been carried out. Risk assessments for falls had been completed, plus for other risks identified. Risk assessments for other identified risks were in some instances very general and needed personalising and expanding. Pressure sore risk assessments were in place and documentation for wound care identified the treatment for and progress of each wound. Continence assessments and care plans for identified continence needs were in place. A new nutritional assessment tool was in place, but some had not been fully Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 10 completed and staff did not all understand how these were to be completed. One service user showed marked weight loss and there was no evidence of action taken to address this finding. For one service user being fed via a percutaneous endoscopic gastrostomy (PEG) tube, the service user plan had not been updated to reflect the change in the feeding regime. The instructions from the Dietician could also not be found. These shortfalls in nutritional management were discussed with the Registered Manager. Moving & handling assessments had been completed. One risk assessment for the use of bedrails was very general and needed expanding to clearly identify the appropriateness of their use. Some service users were seen sitting in wheelchairs with lapstraps in situ. This was tracked in one service user plan and no assessment or consent for the use of a wheelchair lapstrap was seen. Medication records were sampled as part of the inspection. Generally medications are well managed in the home. All medications are stored securely. Receipts and administration of medications were all signed for. PEG feeds are recorded on the medication administration record (MAR) chart and are signed for when commenced. One service user who was prescribed a laxative was requiring it more often than the prescription stated, and this needed discussing with the GP and the prescription altering to reflect this. In one instance where two strengths of a particular medication were required to make up the prescribed dose, the two tablets for administration had not been individually identified on the MAR chart. Liquid medications had not always been dated when opened. The fridge temperature records indicate that at times the maximum temperature exceeded the safe upper range of 8º centigrade. The minimum and actual fridge temperature recordings and room temperature recordings were within safe ranges. The home has introduced the new system of medication disposal in line with current legislation. The medication policy needed to be updated to reflect this change. A list of registered nurse signatures and initials for medication signing identification purposes was not available and the Registered Manager commenced this on the second day of inspection and said that she would ensure this was completed. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Information regarding individual service users social and leisure interests continues to be very general so that each service users interests cannot be planned for and met. EVIDENCE: Care plans for social and leisure interests are very general and do not identify service users individual interests. Therefore the activities programme is not tailored towards meeting service users individual social and leisure interests. This is an ongoing situation at the home. The activities co-ordinator spends one day a week at the home and staff provide activity input at other times. The importance of ensuring that each service users social and leisure interests are considered when formulating an activities programme was again discussed. On the first day of inspection the television was on in the lounge, plus a radio was also on quite loudly. This caused a cacophony of noise and some of the service users appeared disturbed and others very withdrawn. The atmosphere was improved on the second day of inspection and the findings were discussed with the Registered Manager and the Operations Manager. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a clear complaints procedure in place to address any concerns that might be raised by any complainant. Systems for the protection of service users from abuse are in place, and clarity is required to ensure that any concerns are reported and addressed, thus ensuring robust systems for the protection of service users. EVIDENCE: The home has a clear complaints procedure in place, and this includes contact details for the home management and for the CSCI. No complaints had been received. The home follows the Hillingdon Safeguarding Adults procedures. At the time of inspection two service users were noted to have bruises. No entries were seen in the service user plan to identify and explain the causes of the bruising. Staff were able to give a clear explanation for one occurrence, and in the other instance a probable cause had been identified but not recorded. The importance of recording and reporting all incidents to include any unexplained bruising or injury, to include contacting the Hillingdon Safeguarding Adults Coordinator where appropriate, was discussed with the Registered Manager. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 35 The standard of the environment is not satisfactory, and action needs to be taken to bring all areas up to a good standard to provide service users with a homely environment. Ongoing shortfalls in some areas potentially pose a risk to service users and must be addressed. EVIDENCE: During the tour of the home rooms 11 and 17 were identified as in need of redecoration. Cracks were seen in the walls in room 11, the corridor near room 15 and in the ground floor corridor by the kitchen and laundry rooms. There are plans to replace the carpet in three bedrooms and in the ground floor reception and corridor areas in the near future, following redecoration in some areas. The first floor corridor carpet is also worn and in need of replacement. There is an action plan for redecoration, refurbishment and maintenance in place, but this must be reviewed and updated with realistic dates for completion following a full environmental audit. The Operations Manager reported that the cracks and hole in the driveway had been identified as being caused by tree roots, and that action was being progressed to address this. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 14 This progress has been inordinately slow, and it is important that action is taken as a priority to address this situation in full. Documentation has previously been received to state that there is no health & safety risk in respect of this issue, and this information must be reassessed on an ongoing basis and kept up to date. At the last inspection it was reported that one of the first floor bathrooms, which was out of order, was to be converted into a shower room in line with the needs and wishes of the service users, and that this work would be completed by September 2005. This work has not been progressed and the bathroom is still out of order. Some of the requirements for environmental shortfalls identified in the last 2 inspection reports had not all been met. It was noted that the pipe work leading to and from the radiators is still not boxed in or covered, and could pose a risk should someone fall against it. The need to evidence the action carried out to address this shortfall was again discussed. There was still no evidence of the mixer valves being adjusted to produce hot water at 43º centigrade, and regular recordings of 38º and 39º centigrade were seen. The ongoing environmental issues are of concern and action must be taken to address these and maintain this on an ongoing basis. Action had been taken to repair the heating system, with work in progress in one area in the day room. The need to keep the CSCI up to date with the progress being made to address the environmental requirements made in this report was again discussed. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The staffing needs to be reviewed to ensure that the current needs of the service users are being met. Staff have received care training to assist them to meet the general care needs of service users, and recognised induction and foundation training programmes are needed to ensure recognised standards are being met. Employment procedures are satisfactory and safeguard service users. EVIDENCE: A copy of the duty roster was examined. The home has three nurses from overseas on supervised placement. There is evidence that they mainly work on a supernumerary basis on order to shadow the registered nurse. On the first day of inspection the staff allocation did not appear to be able to fully meet the needs of the service users. It was noted that staff were very busy and were working to maximum capacity in order to try and meet the service users needs. This needs to be reviewed in light of the current accommodation of one service user with mental health needs and other service users with a diagnosis of dementia, one of which requires one to one care when their visitors are not present. The home has 5 care staff trained to NVQ in care level 3, plus supervised placement students. There have been no new care staff employed since the last inspection. A general induction document was seen in some staff files, but there is no evidence that the induction and foundation programmes meet the core standards of Skills For Care (formerly TOPSS). Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 16 Two sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001. For one supervised placement student, a copy of their student visa was not available and the administrator said that she had seen this and would follow it up. The records viewed were for supervised placement students as the home has not employed any other new staff since the last inspection. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38 There are robust procedures in place for the management of service users monies, thus safeguarding service users. Shortfalls in the mandatory health & safety training and updates for staff could put service users at risk. EVIDENCE: The home helps to manage the personal allowance for two service users, who have individual bank accounts. Clear records of income and expenditure are maintained on the computer system, with receipts kept for all purchases made. Some of the servicing and maintenance records viewed on the first day of inspection were out of date. On the second day the Registered Manager accessed the records required. These were up to date with the exception of the Landlords Gas Safety Certificate and the Registered Manager said she would follow this up. Staff training records indicated that not all staff were up to date with the mandatory training, for example fire safety, moving & handling, first aid and infection control. This needs to be addressed. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 18 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 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X 1 X X 2 X STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Timescale for action 01/01/06 2. OP4 12, 14 3. OP4 12 The pre-admission assessment process must be reviewed to ensure that service users are fully assessed and accommodation is only offered to those service users the home is registered to accommodate. 01/01/06 Where the behaviour of one service user is impacting on other service users, this must be kept under review and appropriate arrangements made to address the situation. (previous timescale of 01/08/05 not met). A review of placement for any service users whose behaviour impacts on other service users must be carried out and suitable alternative accommodation arrangements made. An action plan with timescales to evidence how these processes are to be progressed must be forwarded to the CSCI. A review of all service users with 01/01/06 cognitive impairment must be carried out. For those service users with a diagnosis of dementia, whose behaviour does DS0000010931.V265087.R01.S.doc Version 5.0 Frithwood Nursing Home, The Page 20 4. OP4 18(1) 5. OP7 15 6. OP7 13(4)© 7. OP8 17(1)(a) 18 8. 9. OP8 OP8 12, 13 13(4)&(7) 10. OP8 13(4)(7)& (8) 11. 12. OP9 OP9 13(2) 13(2) not impact on other service users, a variation to conditions of registration must then be submitted to the CSCI together with the evidence that staff have the skills and the home is equipped to meet the specialist care needs of service users with dementia. All staff must undergo dementia care training to provide them with the knowledge and skills to meet the specialist needs of service users with dementia. The service user plan must fully identify each service users needs and record how these are to be met. Any risks to service users must be clearly identified and the action to be taken to minimise any such risk recorded. Staff must be competent in the completion of all documentation, to include nutritional assessments. All documentation must be fully completed. Evidence of weight loss must be reported and an action plan to address this finding put in place. Bedrail assessments must be completed in full to identify whether or not the use of bedrails is appropriate for the individual. Bedrails must only be used as a last resort and where identified as appropriate. The use of wheelchair lapstraps must be fully assessed to ensure that this is appropriate for the individual and a written assessment must be available. Liquid medications must be dated when opened. All medications must be given in accordance with the prescribers’ instructions. Where a change of dose is required, this must be DS0000010931.V265087.R01.S.doc 01/01/06 01/01/06 01/01/06 01/01/06 20/12/05 20/12/05 20/12/05 09/12/05 09/12/05 Frithwood Nursing Home, The Version 5.0 Page 21 13. OP9 13(2) 14. OP9 13(2) 15. OP9 13(2) 16. OP12 15(1) 17. OP18 13(4)&(6) 18. OP19 23(b)&(d) 19. OP19 23(2)(b) discussed with the GP and the prescription changed accordingly as appropriate. Where more than one strength of tablet is required to be administered to obtain the prescribed dose, these must be individually entered on the MAR chart for each strength of tablet and each strength must be individually signed for. The medications procedures must be updated in line with current legislation to include disposal of medications from Nursing Homes and practices put in place to meet this. The temperature of the medications fridge must be maintained between 2-8º centigrade. The care plans for each service users social and leisure interests must reflect their individual needs and identify how these are to be met. (previous timescales of 01/11/04 and 01/08/05 not met) Any unexplained injury to include bruising must be reported, clearly documented and discussed with the Hillingdon Safeguarding Adults Coordinator. The programmes of redecoration, refurbishment and maintenance must be reviewed and kept up to date, with timescales being met. A copy of the revised programmes must be forwarded to the CSCI. The issues with repairs for the driveway must be satisfactorily resolved. An action plan to show how these issues are to be addressed must be forwarded to the CSCI. (previous timescale 01/09/05 not met) DS0000010931.V265087.R01.S.doc 09/12/05 09/12/05 09/12/05 01/01/06 09/12/05 09/12/05 09/12/05 Frithwood Nursing Home, The Version 5.0 Page 22 20. OP22 23(2)(j) 21. OP25 12, 23(2)© 22. OP25 13(4)© 23. OP27 18 23. OP30 18 24. OP38 13(4) 25. OP38 13, 18 An action plan with timescales to evidence that the home has adequate bathing and shower facilities throughout must be forwarded to the CSCI. The mixer valves on the hot water outlets must be reviewed and water produced close to 43º centigrade. These must be adjusted whenever the water temperature checks reveal a lower or higher hot water temperature. (previous timescales of 10/11/04 and 20/07/05 not met) Evidence that this has been addressed must be forwarded to the CSCI. The hot pipes leading to and from the radiators must be risk assessed and action taken to minimise the risks identified. (previous timescale 01/12/04 and 01/09/05 not met) Evidence that this has been addressed must be forwarded to the CSCI. The staffing levels need to be reviewed in line with the needs of the service users currently accommodated at the home. An action plan to show how this is being addressed must be forwarded to the CSCI. There must be evidence that the home has induction and foundation training programmes that meet the Skills for Care core standards. There must be evidence that all maintenance and servicing is carried out at required intervals, to include the gas systems in the home. There must be evidence that all staff undergo mandatory training and updates at the required intervals. DS0000010931.V265087.R01.S.doc 09/12/05 09/12/05 09/12/05 09/12/05 01/01/06 09/12/05 01/01/06 Frithwood Nursing Home, The Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP27 Good Practice Recommendations A copy of specimen signatures and initials for each registered nurse be maintained for medication administration signature identification purposes. A check be carried out to ensure that all documentation in relation to staff employment details has been correctly copied from the originals supplied. Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Frithwood Nursing Home, The DS0000010931.V265087.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!