CARE HOMES FOR OLDER PEOPLE
Fulwood Lodge Nursing Home 379a Fulwood Road Ranmoor Sheffield South Yorkshire S10 3GA Lead Inspector
Mrs Janis Robinson Key Unannounced Inspection 15th May 2006 09:00 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 Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 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. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Fulwood Lodge Nursing Home Address 379a Fulwood Road Ranmoor Sheffield South Yorkshire S10 3GA 0114 230 2666 0114 230 1713 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) None Silver Healthcare Limited Mrs Susan Farrington Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. One service user who is under the age of 60 and who is named on the application to vary registration dated 05/02/04, may reside at the home. 10 of the beds registered OP for Older People aged 65 years and over, may alternatively be used for the category PD Physical Disability, for people aged 60 years and above and whose disability is related to the ageing process. 15th November 2005 Date of last inspection Brief Description of the Service: Fulwood Lodge is a three-storey home registered to provide nursing care for up to forty-two older people. Thirty single and six double bedrooms are provided, each with en-suite toilet facilities. Each floor has a communal lounge, the ground and first floors are provided with communal dining areas. A central kitchen and laundry serve the home. Sufficient bathing facilities are in place. The home is situated within easy access to shopping centres, pubs, post office and clubs. The bus service to the town centre is a short walk away. The home has pleasant grounds and a car park. Current fees range from £424, to £489. Copies of the homes most recent inspection report, and statement of purpose, are available from the home. A poster was on display in the entrance area, stating that these documents were available and describing what information they contained. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced. A site visit took place over 7.45 hours from 9:00 am to 4:45pm. The inspector carried out an inspection of a proportion of the environment. A selection of records were examined, including, care plans, resident’s finances, complaints, staff training, recruitment and fire records. The manager completed a written questionnaire, prior to the site visit taking place. One written survey was returned by a relative, on behalf of the resident, to give the inspector information on aspects of the home. Ten service users were spoken with, four of whom were able to share their views on living at the home. Two visitors were spoken with, one of whom was a relative of a resident. Discussions with the homes manager and the majority of staff on duty took place. Interactions between staff and residents, the lunchtime meal and part of a drug administration round were observed. The inspector would like to thank the residents, their relatives and the staff at the home for their openness and support of the inspection process. What the service does well:
The majority of the comments made to the inspector were positive. Residents said the staff were ‘kind’ and ‘I am quite happy’. The relative spoken with was happy with the care provided to their loved one and stated that they had good relationships with the staff at the home. The interactions observed and overheard between staff and residents appeared respectful and caring, on the whole. A statement of purpose and service user guide were in place, to provide information about the home to prospective and existing residents. Needs assessments were carried out prior to admission, to ensure identified needs could be met. Residents, a relative and staff confirmed that prospective residents had been able to look around the home and meet other residents and staff before choosing to move in. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 6 Care plans were in place for all residents, these set out in some detail the staff action required to ensure all aspects of care were met. Health care was monitored and access to health care professionals was provided, to maintain health. Systems were in place to ensure the safe storage and administration of medication. The interactions observed between staff and service users appeared respectful. Choices were offered and the routines at the home were flexible. Residents were free to walk around the home. Some social opportunities both in and outside of the home was available, such as trips to the local pub, or shopping. Visiting entertainers were organised for special events. Visitors were welcomed at any time. The visitors spoken with said they were ‘very happy’ with the care their relative received. The homes menu was varied, and choices were offered. Special dietary needs were catered for. Residents told the inspector that they could have a cooked breakfast if they chose. One resident said `you can have anything you want’. The home had a complaints procedure, to ensure any complaint was taken seriously. One complaint had been received by the Commission for Social Care Inspection (CSCI), which was referred to the provider to investigate. Proper procedures had been followed. An adult protection procedure was in place to promote residents safety. The home was well decorated and well maintained, to provide a pleasant environment. Sufficient staff were provided to care for residents. Staff undertook periodic training to keep them up to date. Systems were in place to ensure the safe storage and administration of resident’s monies. All of the people spoken with had confidence in the homes manager. What has improved since the last inspection?
The majority of previous requirements had been met. Several bedrooms had been redecorated and provided with new carpets. New carpeting had been provided to the entrance, staircase and first floor corridor. The reception area had been redecorated and provided with new lighting. The lifts had been repainted, to maintain the environment. The ground floor dining room door had been repaired to ensure residents could exit safely in an emergency. Handrails had been provides to one section of a corridor carpet to ensure residents safety was promoted. A copy of local multi agency adult protection procedures had been obtained to ensure staff had access to, and were aware of, relevant information. A staff-training matrix, and a rolling programme of monthly staff training, had been introduced to ensure staff were provided with relevant training to equip them with the skills needed to carry out their duties. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 7 Staff recruitment files had been audited to check they contained all of the information required, to ensure safe procedures had been followed. The manager had completed NVQ level 4 in management. 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. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 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 Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 5. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. A statement of purpose and service user guide were available, to inform residents and their representatives about the home. Assessments of needs were undertaken prior to admission, to ensure all identified needs of the prospective resident could be met. Prospective residents and/or their representatives were able to visit the home prior to admission, to inform their choices. EVIDENCE: Each resident and their representative had been provided with a service user guide and a copy of the homes statement of purpose, to inform him or her about the home. These contained the full range of information required. A poster was on display in the entrance area, stating that these documents were available and describing what information they contained. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 10 The manager, or deputy manager, carried out detailed needs assessments with all prospective residents and their representatives to ensure identified needs could be met. Copies of social workers full needs assessments were obtained, where available, to provide the home with further information. Families had been involved in the assessment process. The manager confirmed that residents were only admitted to the home once they were sure that they could meet their needs. Prospective residents and their representatives were able to visit the home, have a look around and meet other residents and staff before choosing to move in. The relative spoken with said that this was very helpful in deciding which was the right home for their loved one. They stated that the staff and managers had been very welcoming and supportive, which helped in their decision. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good, further improvements are required to some aspects of standards 9 and 10. This judgement has been made using available evidence and a visit to the home. Each resident had a care plan, to give staff the information needed to ensure all care needs were met. Health care was monitored and assessed, to ensure all individual health care needs were met. Staff respected residents privacy and appeared respectful towards residents, in the main. However, staff need to be reminded of the expectations of their role to ensure residents are fully respected at all times. Medication was securely stored and appropriately administered, to ensure residents were safe and their health was maintained. Staff needed to ensure that safe procedures were followed at all times by routinely recording when medication had been refused or was not required. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 12 EVIDENCE: Three care plans were inspected. They contained all of the information required. They included information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. The plans contained detail of all health care contacts, appointments and treatments, and access to these was available to ensure health was maintained. Moving and handling, and falls risk assessments had been undertaken for all residents to keep them as safe as possible. One member of staff was a qualified tissue viability nurse. Skin risk assessments were undertaken and equipment to aid tissue viability was available. Regular weight checks took place. The manager had a system in place to audit and monitor care plans to ensure they contained relevant, up to date information. Qualified staff reviewed the plans each month. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and residents appeared respectful and caring. Residents made positive comments about their care. Residents said`staff are good to me’ and ‘staff are kind’. However, it was reported to the inspector that some staff routinely held private conversations in communal rooms in the presence of, and excluding, the residents present. This practice is disrespectful and staff must be reminded of the codes of conduct in relation to the expectations of their role. A policy on medication was in place. Medication was stored securely and administered by qualified nursing staff. The drugs held corresponded with the medication administration records. Whilst the majority of administration records were fully completed and up to date, two sheets checked contained gaps where medication that had not been required was not recorded. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is adequate, further improvements are required to some aspects of standard 12 and 15. This judgement has been made using available evidence and a visit to the home. Residents were supported to make choices about how they spent their time, where able. Some activities were offered, to promote choice and maintain interests. Practice could be improved by exploring the provision of further activities more suited to those residents who were unable to participate in planned group events. An open visiting policy was in operation, in order to develop and maintain good relationships with residents’ family and friends. A varied menu was provided and choices were offered to respect personal preferences. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 14 EVIDENCE: Those residents that were able said they were able to get up and go to bed when they chose, and were seen to use different areas of the home according to their preference. Some social opportunities both in and outside of the home was available, such as trips to the local pub, or shopping. Visiting entertainers were organised for special events. Most activities took place on a one to one basis, by staff spending individual time with residents. The residents spoken with said that they did not wish to join in any organised activities. Further residents were unable to participate in any planned events due to their condition or ill health. One relative spoken with felt that more activities should be provided. The Commission for Social Care Inspection received a letter from a relative during the week of this inspection. They stated that, whilst quality of care was good, in their opinion, residents’ lives would be improved if more recreational choices were available. It was evident that residents would benefit from the provision of further activities suited to their individual need. Residents confirmed that they were able to see their visitors in private. Those spoken to said their visitors could come at any time, and the home helped them maintain contact. A visitor said that they were always made to feel welcome. Residents were able to bring personal items with them into the home. All of the bedrooms inspected were individually personalised and very homely. This was important to residents as it helped them retain control over their immediate environment. The menu was varied and a balanced diet was provided to maintain residents health. All of the residents that were able to express an opinion said the food at the home was good, and choices were offered on a daily basis. Alternatives to the two choices on the menu were available. On the day of this inspection one resident had chosen a different meal to the two choices on offer and this had been made available. Residents told the inspector that they could have a cooked breakfast if they chose. One resident said `you can have anything you want’. The lunchtime meal was partially observed. Staff sat with those residents that required help with eating, talked to them and offered assistance respectfully. However, one member of staff was seen to cut up a resident’s meal and start to help to eat whilst standing. The menu on display did not reflect the food provided for the mid day meal. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened to and taken seriously. An adult protection procedure was in place, to ensure residents safety was promoted. Additional guidance had been obtained to ensure staff had access to all relevant information. EVIDENCE: Each resident and representative had been provided with a copy of the homes complaints procedure. A copy was also on display in the entrance area of the home. This contained relevant detail and informed the reader of who to contact outside of the home to make a complaint, should they wish to do so. All of the residents spoken with, who were able to express an opinion, said they had no concerns and could go to the manager and staff to sort out any worries they had. The staff spoken with were confident that the manager would listen to them and taker any complaint seriously. The Commission for Social Care Inspection had received one complaint regarding quality of care. This was being investigated at the time of this inspection. The manager was taking appropriate action to ensure procedures were followed, the investigation was thorough, and the complaint was taken seriously.
Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 16 An adult protection procedure was in place. Staff undertook training on adult protection during their induction to equip them with the skills needed to respond appropriately to any allegations. A copy of local multi-agency adult protection procedures had been obtained to ensure staff were fully aware of all available information. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. Quality in this outcome area is good, further improvements are required to some aspects of standards 19,24 and 25. This judgement has been made using available evidence and a visit to the home. A rolling programme of redecoration and refurbishment was in place, to ensure standards were maintained. The home was clean and well decorated. Communal areas were comfortable and homely. Sufficient bathing facilities were available, with aids and adaptations in place, to assist residents’ personal care needs. All of the bedrooms were well personalised, to create a homely environment for residents. Control of infection procedures were adhered to, to ensure residents health and safety was promoted. A handrail had been provided to one corridor area, to ensure residents were provided with this facility throughout the home. The heating could not be individually controlled in some bedrooms, to afford residents rights and choices. Minor repair work was required to some paving slabs and one bedroom carpet to address potential tripping hazards. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 18 EVIDENCE: An inspection of a proportion of the home was undertaken. The home was well decorated and well maintained. Communal areas appeared comfortable and were provided with pictures and ornaments to create a homely environment. Bathrooms and lavatories were clean and provided with soap and towels. Aids and adaptations, such as hoists and bath seats, were in place to assist with moving and handling. Bedroom furniture was of a good standard and bedrooms were individually personalised. The home had access to a handyperson, to help maintain the environment. A rolling programme of redecoration was in place. Since the last inspection several bedrooms, the reception, staircase and first floor corridor had been redecorated and provided with new carpets. Control of infection procedures were in place. Gloves and aprons were available to staff. Food preparation areas were sited away from laundry facilities. The heating in some bedrooms could not be individually controlled, to provide residents with choice. The patio area had some uneven paving slabs, posing possible hazard. The inspector acknowledges that hazard warnings had been placed in this area whilst repair work took place. One bedroom carpet required attention to repair a potential tripping hazard. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. However, standard 30 met requirements. This judgement has been made using available evidence and a visit to the home. Agreed levels of staff were being maintained to meet the needs of residents. However, some current practices limited the availability of staff. All staff must be reminded of the expectations of their role to ensure they are available to residents at all times whilst on duty. Some staff undertook NVQ training to improve their skills. Recommended levels of NVQ trained staff had not been achieved. A recruitment procedure was in place, however, an audit of staff files was needed to ensure all of the required information had been obtained. A staff training matrix and rolling programme of training had been introduced, to improve practice. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 20 EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained. Residents spoken with felt that enough staff were provided. However, it was reported to the inspector that some staff frequently made routine personal calls on their mobile phones whilst on duty. This practice meant that staff were unavailable to residents at these times. Staff must be reminded of the expectations of their role to ensure they are available to residents at all times whilst on duty. A programme of NVQ training was in place, to ensure staff developed the skills required to carry out their duties. Of the twenty-one care staff, two staff had achieved NVQ level 2 in care. Four further staff were undertaking the training at levels 2 and 3. A policy and procedure for staff recruitment was in place. Two staff files were inspected. These contained all of the required information and included proof of identity, CRB checks, a contract and two written references. However, whilst application forms obtained information on previous work history, evident gaps had not been explored in one file. The inspector acknowledges that this information was obtained during the inspection. An audit of all staff files must take place to ensure this information is in place for every member of staff. Since the last inspection staff training had improved. The manager had undertaken a matrix, to provide ‘at a glance’ information. A rolling programme of staff training had been introduced, and training events took place on a monthly basis, to ensure staff had all of the skills required to undertake their duties. Individual training profiles were maintained. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,37 and 38. Quality in this outcome area is good, further improvements are required to some aspects of standards 33 and 38. This judgement has been made using available evidence and a visit to the home. The manager’s leadership approach benefited residents and staff. The manager was appropriately qualified to ensure she had the skills and competencies required to fulfil her role. A quality assurance system was in operation, to obtain the views of residents. Some improvements to this system were required to ensure residents and their representatives had been provided with relevant information. Insurance cover was in place and the home had a business plan to ensure financial viability. Systems for handling residents’ finances were in place, to ensure safe procedures were followed. Records were stored securely, to protect confidentiality. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 22 Health and safety systems were maintained to ensure residents lived in a safe environment. Staff undertook mandatory training to ensure they had the essential skills required to undertake their duties. However, staff needed to ensure that footplates were used on wheelchairs at all times, to ensure residents were moved safely. EVIDENCE: The manager was a qualified nurse and had recently completed NVQ level 4 in management. All of the staff spoken to said the manager was approachable and supportive. Residents said that they `could talk to her about anything’. Insurance cover was provided and a relevant certificate was on display in the reception area. Quality assurance system was in operation. Annual surveys were undertaken with residents, where able, and their representatives. The results of these surveys required publishing to ensure this information was available to all interested parties. Residents financial systems were inspected. Individual records of financial transactions were recorded, and all receipts were retained. Residents received interest on their bank accounts. Money was stored securely. Records were stored securely at the home, and residents had been informed of their rights to access their care plan. A health and safety policy was in place. Systems were checked and serviced to maintain a safe environment. Weekly fire alarm checks were recorded. A mandatory staff-training matrix was in place, to ensure staff were up to date with all relevant training. A rolling programme of monthly mandatory training had been introduced. All staff were up to date with mandatory training, with the exception of two night staff that required food hygiene training. The inspector acknowledges that these staff had been booked on the next training event. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 X 3 2 Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 24 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 OP9 Regulation 13 Requirement Medication administration records must be fully completed. Where medication is refused, or not required, this must be recorded. All staff must be reminded of the expectations of their role and adhere to these. Residents must be treated with respect at all times. Private, exclusive conversations between staff in the presence of residents must not take place. Further activities, suitable for individual residents, must be identified and provided. Staff must offer assistance with eating in a manner that respects the dignity of the residents. Staff must sit to assist with eating at all times. Timescale for action 15/05/06 2 OP10 OP27 12 15/05/06 3 4 OP12 OP15 16 12 01/08/06 15/05/06 5 OP19 13 The menu displayed must accurately reflect the main meals provided. All parts of the home must be 01/07/06 safely maintained. The uneven paving stones outside the dining room must be
DS0000021778.V293580.R01.S.doc Version 5.1 Page 25 Fulwood Lodge Nursing Home made safe. (Previous timescales of 31/12/05 not met) 6 7. OP24 OP25 13 16 The identified bedroom carpet must be made safe or replaced. The heating system must be updated to enable residents to control the heating in rooms. (Previous timescales of 01/11/05. and 01/03/06 not met) All staff must be reminded of the expectations of their role and adhere to these. Staff must be available to residents at all times whilst on duty. Regular, routine personal calls must not be common practice. A minimum of 50 of the care staff team must be trained to NVQ level 2 in care. An audit of staff recruitment files must be undertaken. Files must evidence that gaps in employment history have been explored. (Previous timescale of 31/01/06 not met) The results of annual surveys must be published and made available to residents and their representatives. Footplates on wheelchairs must be used at all times, unless a written risk assessment evidences that this is not in the best interests of the resident. 01/07/06 01/08/06 8 OP27 12,18 01/08/06 9 10 OP28 OP29 18 18 01/09/06 01/08/06 11 OP33 24 01/08/06 12 OP38 13 15/05/06 Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 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 Refer to Standard OP12 Good Practice Recommendations Residents, where able to express an opinion, and their representatives, should be consulted regarding the provision of activities. The views obtained should be taken into account. Fulwood Lodge Nursing Home DS0000021778.V293580.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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