Inspection on 20/06/07 for Greasbrough Residential Nursing Home

This inspection was carried out on 20th June 2007.

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

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

Other inspections for this house

Greasbrough Residential Nursing... 21/05/09

Greasbrough Residential Nursing... 01/03/06

Greasbrough Residential Nursing... 02/08/05

Greasbrough Residential Nursing... 25/11/04

Greasbrough Residential Nursing... 22/07/04

Greasbrough Residential Nursing... 01/07/03

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

CARE HOMES FOR OLDER PEOPLE Greasbrough Residential / Nursing Home Potters Hill Greasbrough Rotherham South Yorkshire S61 4NU Lead Inspector Ramchand Samachetty Key Unannounced Inspection 09:45 20th June 2007 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 DS0000003078.V330587.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. DS0000003078.V330587.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greasbrough Residential / Nursing Home Address Potters Hill Greasbrough Rotherham South Yorkshire S61 4NU 01709 554644 01709 559332 NONE 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) Dr M. H. Husain Mrs. J. M. Husain Susan Briggs Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability (60) of places DS0000003078.V330587.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit up to three service users between the age of 60 to 65 years in the category for Old Age which the home is registered 1st March 2006 Date of last inspection Brief Description of the Service: Greasbrough Nursing and Residential Home is registered to provide accommodation and care for up to 60 older people. The home is situated on the main road in the centre of Greasbrough, on the outskirts of Rotherham. Dr. M H Hussain, OBE and Mrs. J M Hussain own the home and the day- to- day management is entrusted to the home’s manager. The building is on two levels and there are passenger lifts to facilitate access between the floors. There are bedrooms and communal areas located on both levels. The main lounge, the dining room and the kitchen are located on the ground floor. The laundry is based in the cellar. All bedrooms are for single occupancy and have en-suite facilities. There is a pleasant courtyard within the centre of the building and there are other garden areas. There is a car park to the rear of the home. There service is a statement of purpose and a service user guide. These documents give more information on the home and its facilities. The fees charged as at 20 June 2007, were between £350.00 and £450.00 per week. Further information can be obtained from the home. DS0000003078.V330587.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out on 20 June 2007, starting at 09.45 hours and finished at 18.45 hours. The service is registered to provide nursing and personal care for up to 60 older people. There were 56 people in residence at the time of this inspection. The registered manager had left her post and the provider has recruited and appointed a new manager, Ms Bev Cuckson, a first level nurse who has worked at the home for some time. Ms Cuckson was present throughout the inspection. The responsible individual, Dr M.H.Hussain was also present for part of the inspection. All the key national minimum standards for “Care Homes for older People, were assessed. The inspection included a tour of the premises, examination of care documents and other records, including those pertaining to staff rota, complaints, maintenance of equipment and systems, staff and medicines records, also conversations with two relatives, six people living at the home and five members of staff, including the manager. The care of two people was also tracked and some aspects of care provision were observed. As part of the pre-inspection planning, the completed questionnaire submitted by the registered provider and other documents, including comment cards received from people who use the service and their relatives, were considered. The views and comments expressed in them have been included in this report. The inspector would like to thank all the people using the service, their relatives and staff who helped with this inspection. What the service does well: The building was well maintained and the standard of private and communal accommodation provided was very good. People who use the service and their relatives said that they were satisfied with the service being provided. They stated that staff were very “caring and friendly”. They praised the standard of both the nursing and personal care that they were receiving. There was a good staff team, which worked well together to ensure the continuing wellbeing of people living at the home. The home was well organised and the day-to day operations were well conducted through the efforts and support of the registered provider and a group of senior staff. DS0000003078.V330587.R01.S.doc Version 5.2 Page 6 Health and safety measures regarding the building and work practices were professionally and satisfactorily addressed. What has improved since the last inspection? What they could do better: Although a home manager has been appointed, there is a need for the person to apply for registered manager status with CSCI. There is a need to improve the service user guide by including up to date information on the home’s complaints procedure and a copy or a summary of the most recent CSCI inspection report. Although people who use the service were satisfied with the care they were receiving, the records of care provided could be improved to better reflect the standard of care practised. Meals provided at the home were well liked, but there is a need to improve the choice of main courses and menus must be appropriately displayed at the home. There is a need to plan social and recreational activities in a way that takes account of the preferences and capabilities of all the people who use the service. A recommendation has been made for staff to record the views and experience of people who take part in social and recreational activities, in their care files. A phone facility, which provides privacy, must be provided for the benefit of the people who live at the home. Arrangements must be made so that people living at the home can access their personal monies at all reasonable times beyond office hours. The management of medicines must be improved to avoid a number of minor shortfalls. There is a need to develop and implement appropriate quality monitoring and quality assurance methods in order to improve the overall management of care. DS0000003078.V330587.R01.S.doc Version 5.2 Page 7 The registered provider must review and increase the number of hours worked by first level nurses in line with the staffing notice served by the previous registering authority and also to meet needs of people using the service. Although improvement work on the building has led to a more pleasant entrance area and more comfortable seating arrangements in the lounge areas in the front, staff should make sure that every effort is taken to safeguard and promote the dignity and privacy of people who use these areas, which are also accessible to members of the public. 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. DS0000003078.V330587.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 DS0000003078.V330587.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 and 3. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People using the service and those who were interested to use it, were given sufficient information to help them with their choice. However, the service user guide lacked up to date information about the home’s complaints procedure and a copy of its last inspection report. Assessments of needs were carried out before people were admitted to the home, in order to make sure that their care needs could be met. EVIDENCE: The home had produced a statement of purpose and a service user guide. Copies of both documents were available to people who use the service. Staff confirmed that these documents were also given to people who were interested in obtaining a placement at the home. DS0000003078.V330587.R01.S.doc Version 5.2 Page 10 People using the service and their relatives stated that they were given sufficient information to enable them to choose whether the home was right for them. The service user guide contained information about the facilities provided by the home. However, it did not include a summary of the most recent inspection report. The manager stated that a copy of the inspection report was available to any one who wanted it. The service user guide also contained an old copy of the complaints procedure, which was not based on best practice. The care records of two people who were recently admitted to the home were checked. They showed that assessments had been appropriately carried out before being admitted to the home. The home does not provide intermediate care. DS0000003078.V330587.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 and10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living at the home were satisfied with the care they were receiving, which they felt was helping them in their daily activities of living. Their assessed needs were addressed in individual care plans to ensure they were catered for. A policy and procedures for safe administration of medicines was in place, but staff were not implementing it satisfactorily. There was a lack of monitoring and regular audits to ensure best practice was encouraged at all times. These shortfalls could affect the wellbeing of people living at the home. DS0000003078.V330587.R01.S.doc Version 5.2 Page 12 EVIDENCE: People who use the service and their relatives stated that they were satisfied with the care that was being provided at the home. They said that staff were “good and friendly”. People living at the home said that personal care was provided to them in the privacy of their own bedrooms and in bathrooms. They commented that staff always addressed them with respect. People living at the home were observed to be in good attire and this helped to maintain their dignity and self-confidence. The care plans of two people using the service were checked. They were based on identified personal and health care needs and risks. Actions to be taken to meet the needs of individuals were appropriately set out in their care plans. One care plan was noted to provide good guidance on the management of a pressure sore and on maintaining skin integrity. However, records of care provided were often too generalised and lacked details of care provided. This was particularly evident in the records of care given at night. The inadequate recording of care interventions often led to a poor evaluation of care. People using the service said that their health care needs were well met. They had visits from various health care professionals, including their GPs, chiropodists, opticians and dentists. There was a policy and procedures regarding the management of medicines at the home. None of the people living at the home were self-administering their medicines. Staff who administered medicines were either nurses or carers who had received accredited training in the safe handling of medicines. The storage, handling and administration of medicines were checked. The storage of medicines was satisfactory. Medicines administration record (MAR) sheets were checked. They showed that on a few occasions, the amount of medicines received from the chemist was not recorded. A few handwritten entries on the medicines administration records were not dated and signed by the writer to confirm authorisation. In discussion, it was noted that a representative from the chemist (Boots) had visited the home to advise on the medicines administration procedures. There was no internal audit tool to monitor the management of medicines at the home. DS0000003078.V330587.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living at the home were satisfied with the daily routines and felt they could still exercise some choice. Social and recreational activities were organised but they did not seem to be accessible to those who were frailer and more dependent. Although people living at the home were satisfied with the meals that were provided, the menus did not reflect the food choices they could have. DS0000003078.V330587.R01.S.doc Version 5.2 Page 14 EVIDENCE: On the day of this inspection, people living at the home were observed to spend most of their time sitting in the lounges in between meals and care interventions. The inspector observed that there were about twenty people sitting in the lounges near the front entrance of the home. There was a volunteer who stayed at the reception desk, which was located between the two lounge areas. It was noted that there was no facility for people living at the home to have use of a phone, which they could use independently and in private. Staff said that there was no leisure activity planned for the day and some people would do what they liked. People living at the home said that they were offered opportunities to take part in leisure activities. A member of staff was employed as a welfare officer/ administrator and she said that she was responsible for organising social and recreational activities. She said that she consulted people who use the service about what activities they liked and then organised them. A record of activities held was kept separately and was not included in the daily records of care given. It showed that a number of people had taken part in recreational activities like bingo; quiz nights, outings to the theatre and the church and entertainment shows. The records contained comments about people who took part in leisure activities. These comments were not included in care records and therefore were not part of any care evaluation. A relative commented that her loved one was not capable in taking part in activities organised by staff, because of her frailty, but she could still benefit from some social stimulation, if provided. The record of activities did not indicate how the social care needs of people who were physically less able to participate in them were catered for. Relatives, who spoke to the inspector, said that they were always welcomed at the home. There was good communication between themselves and the staff. They also commented positively on the way birthdays of people living at the home were marked, with their consent. DS0000003078.V330587.R01.S.doc Version 5.2 Page 15 People using the service said that they found daily routines to be flexible. They said that they were able to choose what time to get up and to retire to bed and they could choose where to have their meals. People using the service stated that the meals served at the home were “good and nourishing”. The lunchtime meal was observed. The day’s menu was not displayed but a copy was kept by the cook. Staff explained that they checked the meal preferences of people every day and passed the information to the cook. The menu for the day consisted of chicken casserole, as the main protein part of the meal, chips and vegetables. Two people were served with an alternative meal consisting of fish and chips. The choice of meals was rather limited as people could only choose between the main protein part of the meal or an alternative. Condiments and a variety of deserts and beverages were also served. Care staff were observed assisting people, who had difficulty partaking their meals, in an appropriate and unhurried manner. DS0000003078.V330587.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 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living at the home and their relatives were aware of the home’s complaints procedure and could use it if they had to. However, concerns, which were received and dealt with, were not adequately recorded. There was an adult protection policy and staff had knowledge and understanding of it and were able to safeguard people in their care. EVIDENCE: There was a complaints procedure in place and it gave information on how to make a complaint and who would deal with it. It also gave the timescale within which a complaint would be investigated and concluded. The complaints procedure was included in the statement of purpose and service user guide and a copy was also displayed on a notice board. DS0000003078.V330587.R01.S.doc Version 5.2 Page 17 Some people living at the home and their relatives said that they were aware of the complaints procedure and would use it if they had reason to do so. They said that they usually talked to staff if they had any concerns and these would be dealt with in a prompt manner. The home had received no complaints. Staff explained that concerns from relatives were recorded in a section of the care notes of individuals. A sample of care records was checked. They showed that areas of concerns were recorded in the ‘ Relatives Comment Sheet’ but action taken to address such concerns were not always recorded. There was also an adult protection policy in place to promote the safety and welfare of people living at the home. Staff were aware of this policy and staff had received training on its implementation and on issues of safeguarding vulnerable adults. There had been no adult protection issues at the home. DS0000003078.V330587.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 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living at the home were satisfied with the standard of accommodation and its facilities, which together make the place comfortable and pleasant. However, the location of a reception desk in the vicinity of the lounge areas could compromise the privacy and dignity of people using this part of the home. EVIDENCE: People living at the home were satisfied with the standard of accommodation. They stated that both the communal areas and their bedrooms were always kept clean and tidy. A few bedrooms were checked with the permission of people who lived in them. They commented that they were able to personalise their bedrooms with their own items of memorabilia. DS0000003078.V330587.R01.S.doc Version 5.2 Page 19 The inspector undertook a tour of the premises in the company of the manager. The main entrance of the home was wheelchair accessible. The front entrance leads straight on to a reception desk located in between the two parts of the main lounge areas. This meant that visitors to the home were able to walk into the lounge areas where people using the service would be sitting and spending their time. This could compromise the dignity and privacy of people living at the home. There were a number of communal areas, which people could use during the day. They were all well furnished and provided pleasant and comfortable environment for all. There were two dining rooms and it was noted that a hot trolley was used to transport meals to one of the dining rooms. People living at the home had no concerns about this arrangement. Laundry facilities were adequately provided so that bedding could be washed at the correct temperature to reduce the risk of infection. The home was well maintained and was in good decorative condition. The surrounding grounds were also well maintained. One lounge area leads to a patio, pleasantly set out with shrubs and some garden furniture. DS0000003078.V330587.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 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Although people living at the home said that they were, in general, receiving a good standard of care, the staffing level, in particular for nurses, was not sufficient to meet the needs of the people concerned and for the manager to effectively manage. Recruitment and selection procedures were not robustly implemented and this led to inadequate pre-employment checks to be carried out before care staff started to work at the home. DS0000003078.V330587.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home was registered to care for up to 60 people. There were two first level general nurses and six care workers on duty on the morning of this inspection. There were 56 people in residence and 41 of them required nursing care and 15 required personal care only. In the afternoon, from 12.30 pm onwards, there was only one first level nurse on duty and six care workers. The duty rota showed that there was usually one first level nurse in the afternoons. There was one first level nurse and four carers on night duty. The staffing level was on occasions reduced due to holiday leave and other staff absences. This was evident from the duty rota that was checked. There was also no evidence that the level of staffing was calculated on needs of people using the service. The registered manager of the home had left and the owner had recruited one of the nurses currently employed at the home to the post and she was currently acting up as manager. However, the duty rota showed that she was working most of her 38 hours undertaking nursing duties at the home. The owner explained that he had also employed two other members of staff to assist with the administration of the home. However, their job descriptions showed that they had areas of responsibility that were the within the remit of a “registered manager”. There was therefore a lack of clarity about the responsibility and accountability of this group of senior staff, including the appointed manager. It was also noted that there was a volunteer who was helping at the home. She was observed working at the reception desk for most of the time. In discussion, people who live at the home and their relatives were satisfied that there were currently enough staff to provide the care and support that was needed. They also commented that the nurses worked “ very hard and were rushed off their feet”. People, who completed a survey about their views on the service, stated that on occasions the home was short staffed. An individual stated that because of staff absence, sometimes, things like “getting a shower was often deferred to the following week. The pre-inspection questionnaire completed by the manager indicated that the home had a recruitment and selection policy. It was noted that this policy included the practice of equal opportunities. However, only two of the care DS0000003078.V330587.R01.S.doc Version 5.2 Page 22 workers were male. A number of nurses were from abroad and were of Black and Asian origins. The records of two members of staff who had been recruited since the last inspection, were checked. In one instance all the procedures, including the pre-employment checks were satisfactorily carried out. In the other instance, the CRB that was produced was from an ex-employer and was therefore not relevant to the post the staff member had applied for. It was noted that the Volunteer had also obtained her CRB, before taking up her role at the home. There was evidence that the appropriate induction was provided to the new recruits. Staff spoken to stated that they had received training on a range of subjects, including first aid, moving and handling, food hygiene, fire safety, adult protection and the handling of medicines. The manager stated that refresher training on moving and handling, first aid and health and safety had been arranged to take place at the end of June 2007. The pre-inspection questionnaire completed by the manager indicated that 56 of the care staff had achieved their NVQ level 2 in Care. It was noted that other care staff were currently undertaking their NVQ training. DS0000003078.V330587.R01.S.doc Version 5.2 Page 23 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, 33, 35, 36 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Although a newly appointed manager was in post, the home was well managed to ensure the safety and welfare of people who live in it. However, quality monitoring and quality assurance methods were not well developed to support the management of care. DS0000003078.V330587.R01.S.doc Version 5.2 Page 24 EVIDENCE: The new manager is a first level registered nurse with experience of working in this care setting. She stated that she had enrolled on the Registered Manager Care Award. She was currently in the process of submitting her application for registration to CSCI, as the home’s manager. It was noted that the registered provider was providing a good level of support to the newly appointed manager. In discussion with the registered provider, it was noted that two other staff were employed to undertake some management responsibilities at the home. However, there was a lack of clarity on the job roles of the manager and the two staff who had also been given the responsibility of managing. It was not clear, for example, who among the post holders had responsibility for monitoring of care, recruitment of staff, staff training and complaints investigation. The manager explained that quality satisfaction questionnaires were periodically distributed to people who use the service and their relatives. Feedback obtained from these questionnaires was discussed at staff meetings. Staff were satisfied with the communication methods in place to keep them informed of all care and management issues. The manager also commented that regular “Residents” meetings were held and the views and comments received from them were used to improve the provision of care. It was noted that the home had achieved the “Investors in People Award”. There was evidence that the registered provider was undertaking regular unannounced visits and reporting on them. However, there was no quality monitoring tools in place to assist the manager in her tasks, with regards for example to, an internal audit system for medicines management and care plans monitoring. Arrangements were in place to support people living at the home with the management of their personal allowances. However, people who had their money in the safekeeping of the home had no access to it, after office hours. All financial transactions were appropriately recorded, witnessed and signed for and receipts were kept. Accounts checked were in balance. DS0000003078.V330587.R01.S.doc Version 5.2 Page 25 Staff confirmed that they were receiving regular supervision and support from the manager and the senior care staff. There was a supervision programme in place. It was also noted that staff had received their yearly appraisals. DS0000003078.V330587.R01.S.doc Version 5.2 Page 26 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 2 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 3 X 3 DS0000003078.V330587.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The service user guide must be amended to include a revised copy of the home’s complaint procedure and a copy/summary of the most recent inspection report of CSCI. The records of care provided must be improved to reflect details of actual care and support provided to people living at the home and to assist in care evaluation. The management of medicines must be improved to make sure that the receipt of medicines at the home is appropriately recorded. Handwritten entries on medicines administration records must be signed and dated by the person who writes them. An internal regular audit of medicines must be developed and carried out, with records kept. A phone facility must be provided for use, independently and privately, by people who live at the home Social and recreational activities DS0000003078.V330587.R01.S.doc Timescale for action 06/08/07 2 OP7 15 06/08/07 3 OP9 13 06/08/07 4 OP12 16 03/09/07 5 OP12 16 06/08/07 Page 28 Version 5.2 6 OP15 16 7 OP16 22 8 OP27 18 9 OP29 19 10 11 OP31 OP33 8, 12 24 12 OP35 16 must be planned in advance and in consultation with people who use the service, in order that their preferences and capabilities are duly considered and catered for. Menus must offer at least two choices of the main course to enable people to make an effective choice. Menus must be appropriately displayed in the home, for the benefit of people who using the service. Actions taken to address and resolve concerns that are expressed by people using the service and their representatives must be appropriately recorded. The number of hours worked by first level nurses at the home must be increased to at least 252 hours per week and this must be increased if dependency of people using the service increases. For the number of nursing beds available at the home, all the hours worked by the manager must be supernumerary and therefore not included the nurse staffing level. All pre-employment checks must be appropriately carried out and must include CRBs, before staff start working at the home. An application for registration of a manger must be submitted. Appropriate quality monitoring and quality assurance methods must be developed and used at the home in order to improve the overall management of care. Arrangements must be made for people to access their money at all reasonable times beyond office hours. 06/08/07 06/08/07 20/08/07 06/08/07 06/08/07 20/08/07 06/08/07 DS0000003078.V330587.R01.S.doc Version 5.2 Page 29 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 OP12 OP19 Good Practice Recommendations Records and comments concerning social and recreational activities by people using the service should be entered in their daily records. Care should be taken at all times to make sure that the dignity and privacy of people who choose to sit in the lounge areas near the entrance of the home, is safeguarded and promoted. Therefore no personal care should be routinely provided in this communal area, which is also accessible to members of the public. DS0000003078.V330587.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000003078.V330587.R01.S.doc Version 5.2 Page 31 - 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. 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