Inspection on 11/12/07 for Grey Ferrers Nursing Home

This inspection was carried out on 11th December 2007.

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

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

Other inspections for this house

Grey Ferrers Nursing Home 17/05/09

Grey Ferrers Nursing Home 22/05/08

Grey Ferrers Nursing Home 02/07/07

Grey Ferrers Nursing Home 05/07/06

Grey Ferrers Nursing Home 20/09/05

Grey Ferrers Nursing Home 28/04/05

Grey Ferrers Nursing Home 02/08/04

Grey Ferrers Nursing Home 06/05/04

Grey Ferrers Nursing Home 03/03/04

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

CARE HOMES FOR OLDER PEOPLE Grey Ferrers Nursing Home Priestly Road Blackmore Drive Leicester Leicestershire LE3 1LQ Lead Inspector Claire Williams and Angela Kennedy Unannounced Inspection 11th December 2007 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 Grey Ferrers Nursing Home DS0000001907.V354926.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. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grey Ferrers Nursing Home Address Priestly Road Blackmore Drive Leicester Leicestershire LE3 1LQ 0116 2470999 0116 2558364 brownpj@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd 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) Mrs Pamela Jane Brown Care Home 120 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons who fall within category DE(E) may only be admitted into Stewarts Hey & Woodville House Unit located at Grey Ferrers Nursing Home Bradgate Unit located at Grey Ferrers Nursing Home may accommodate a total of 30 persons who fall within categories/combined categories OP and PD(E). Brandon House located at Grey Ferrers Nursing Home may accommodate a total of 30 persons who fall within categories/combined categories OP and PD(E). No person falling within either category OP or PD(E) may be admitted to Grey Ferrers Nursing Home when an overall total of 60 persons who fall within those categories are already accommodated within this home. The registered provider is able to admit into Grey Ferrers Nursing Home the person of category DE, named specifically in variation application number V43335 dated 18 February 2003, who is under 65 years of age. Th The registered provider is able to admit into Grey Ferrers Nursing Home the person of category MD(E), named specifically in variation application number V55305 dated 13 September 2003. The registered provider is able to admit into Grey Ferrers Nursing Home the person of category MD(E), named specifically in variation application number V55305 dated 13 September 2003. That Grey Ferrers Nursing Home is registered to admit one named Service User, named in application number V29612, under category PD. The maximum number of persons to be accommodated within Grey Ferrers Nursing Home is 120. To be able to admit the named person of category DE (under 65 years) named in variation V35650 dated 5th October 2006 into Grey Ferrers Nursing Home The registered provider is able to admit into Grey Ferrers Nursing Home one person under the category PD 50 - 65 years of age 5. 6. 7. 8. 9. 10. 11. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 5 Date of last inspection 2nd July 2007 Brief Description of the Service: Grey Ferrers is a 120-bedded care home providing personal and nursing care for older persons. Accommodation is provided within four separate units, these are known as Brandon, Bradgate, Stewards Hay and Woodville providing care for older persons with nursing, physical disability and dementia needs. Each unit is comprised of a large dining/ lounge area, a small quiet lounge, toilet, washing and bathing facilities and single room private accommodation. The home is located on the outskirts of Leicestershire and is easily accessed by public transport from the City of Leicester and from the County. The home is purpose built and is accessible to service users with disabilities. Accommodation is located on the ground floor. Each unit has a spacious lounge and adjacent dining area, which look out over the gardens. All bedrooms are single occupancy and all are ensuite, many open directly onto the garden. The home is currently managed by a registered nurse and employs Registered General nurses, Registered Mental Health nurses and care staff. The home has ample parking and is close to a number of social amenities. The weekly fees range from £327 to £685 per week. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, newspapers, etc. The home provides information to residents and prospective residents in the form of a Statement of Purpose that describes the services it offers, with copies of the Service Users Guide and the last Inspection Report displayed in the reception area. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key unannounced inspection that took place at the home over a period of 2 days. On day one two inspectors visited the service accompanied by a pharmacy inspector and an expert by experience. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. On day two the lead inspector visited and completed the inspection. During these two days all of the four units were visited and documents were examined. In additional to this staff, relative’s, residents and the unit managers were spoken to. Time was also spent with the Registered manager, Regional manager and the Quality assurance manager who were present on both days. Additionally, time was spent in preparation for the visit, looking at previous inspection reports and the annual quality assurance assessment, which had previously been completed by the Registered manager. In order to obtain feedback about the service surveys were sent to staff, residents and their families. There comments have been included in this report. What the service does well: Residents and their relatives have an opportunity to visit the home in order to see if it meets their expectations. Following a comprehensive assessment resident’s and their families felt confident that the home is able to meet their needs. Relatives spoken with commented on the support they had received from the staff team, during this sensitive and emotional time. Staff demonstrated patience and understanding when caring for residents and were motivated and enthusiastic about their roles. Staff have access to training opportunities to ensure they have the required skills and knowledge to fulfil their roles and deliver quality care and support Comments from relatives supported that residents are well looked after and relatives were reassured that the person living at Grey Ferrers was safe when they were not there. Relatives have spoken positively about the staff team, and said that they are kept informed of any changes, and are involved in the care plan reviews and the development of care plans. Relatives attend meetings facilitated by each unit and felt this was positive as it enables them to be involved and raise any issues. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 7 Residents are encouraged to remain as independent as possible and use all areas of the home as they wish. Staff encourage and assist residents where necessary and they are offered a range of leisure activities. 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. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 8 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. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 9 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 Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 10 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): National Minimum Standards 1 and 3 (standard 6 not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process ensures that people’s needs are identified and met. EVIDENCE: Information about the home is provided in the Service user guide and Statement of purpose. Both of these documents are available and all individuals are provided with a copy of the Service user guide. Feedback from people consulted confirmed that they were provided with information about the home, and had the opportunity to visit for a trial period or a day visit to see what the home was like. People commented on the support they received from the staff and management team, during their transition to the home. All four files examined contained assessments of need, one completed by their respective Care Manager and an assessment was completed by a unit manager from the home. This provides the staff and management team, with the required information in order to implement a care plan. Grey Ferrers Nursing Home DS0000001907.V354926.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): National Minimum Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People needs are met in accordance with their preferences, and in a manner, which promotes their rights to dignity, privacy and respect. EVIDENCE: All of the residents’ files examined had care plans in place, which had been written from the assessments of their care needs and provide staff with the information required to care and support each resident. The care planning documentation is comprehensive and covered all areas applicable to the needs of the individual. There was evidence in the files to support that the individual or their family had been involved in the development of the plan. This involvement was also supported by comments received from a relative who stated, “we were asked lots of questions and helped to complete the paperwork they were very thorough” The various components of the care plans were written from the individuals perspective, and were detailed providing direction to staff on how to meet that particular need. However in two of the care plans the handwriting was difficult Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 12 to read which could prevent staff from accessing this information. There was evidence to support that each area is reviewed on a monthly basis, and relatives confirmed their involvement in the formal reviews. In response to the previous inspection report, a lot of work has been undertaken to obtain more information about the individuals past lives and social networks. A ‘map of life’ document has been implemented to record this information and this provides an overview of the person’s previous life history. This information is helpful to care staff as it enables them to gain essential knowledge about a person, especially for individuals who have dementia and individuals who are not able to communicate about their past. Some information was available concerning individuals daily routines in respect of rising and retiring times, which is helpful to staff as this enables them to support individual’s based on their preferences. This information however was not available in all four care plans. Risk assessments were in place and assessments was completed for all identified risks and these linked in with the care plan. The staff team were observed using appropriate techniques and equipment when transferring people and they explained to the individual their actions before they completed tasks. There was evidence to support people have access to health care professionals and records were completed in response to appointments detailing the outcome. Observation of staff throughout the visit and comments from relatives indicated that staff were attentive to residents needs and acted appropriately. Staff were observed being involved with residents and helping them in ways that respected their privacy and dignity at all times. They were observed using various communication techniques so that the wellbeing of people is maintained, an important aspect of the care of people who suffer from dementia. A CSCI Pharmacist Inspector undertook a full inspection of medication on each unit. No residents were looking after their own medicines at the time of the visit but records are kept showing that residents have been offered this choice if they want to and are able to. Clear records are kept to show that the correct medicines have been obtained and given to residents and that unused medicines have been disposed of safely. Senior staff make regular checks to ensure that medicines are being given and looked after properly. Medication policies and procedures are in place that staff understand and follow. A nurse said that they had received medication training from BUPA the previous year and had recently had some training on how to take blood. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 13 Handwritten medication administration records are generally accurate but two records were seen that did not contain correct administration instructions. Risk assessments and care plans do not contain details about medicines to ensure that staff always have enough information about how they should be used for example when needed only occasionally or when they are given by specialised methods. Medicines are stored securely but fridge temperatures are not being taken correctly to check that they stored within the recommended temperature range. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 12, 13, 14, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: The care files contained some information in relation to residents preferred activities, social interests and religious observance. There are two activity organisers employed on a part-time basis, who alternate their time between the four units. They provide a varied range of activities both on a group and individual basis. They said they aim to ensure they interact with all residents and ensure that any residents who are in their rooms are visited for social stimulation. There was activities programmes displayed in all units. On the dementia care unit there are memory boxes and some photos to assist people with their orientation within the home. The activity organisers stated that although they have attended Dementia care training this was a long time ago. Residents were observed reading newspapers and books and walking around as they wished. The care staff were observed interacting with residents but this was mainly task focused. Staff members consulted stated that they do Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 15 try to spend ‘quality time’ with residents but this can be difficult due to their role. One care staff was observed painting a residents nails which she seemed to enjoy. The ‘expert by experience’ observed one of the activities organiser facilitate a quiz in one of the units, which she said was ‘very popular with those able to participant with the help and encouragement of visitors’. She also spoke with relatives who commented to her that they felt “not enough was done to stimulate their family member especially after strokes. Relatives felt that more activities should be facilitated. The expert by experience stated that she observed more activities such as painting nails and hand massages on the dementia care units. She felt the input from visitors was noticeable as they “came to help and assisted individuals to eat”. It was reported that a variety of entertainment is arranged across all of the units and trips out are facilitated. Each unit arranges a Christmas party, which is held on different nights, and a relative who had attended said, “it was good fun and the staff worked very hard”. Feedback from residents and their relatives indicated that they generally felt the provision of activities was satisfactory. All visitors consulted said they are made to feel welcome in the home, and no restrictions on visiting times were in place. They felt well informed about the general care and well being of their relative and said communication was good between them, the unit managers and the staff team. We joined the residents for their lunchtime meal. The ‘expert by experience’ felt the menus were well displayed and found the content and choice to be impressive. She observed the staff in all units encouraging people to drink to avoid dehydration. Residents are asked their food preferences in the morning, and the staff members make the decision on behalf of those residents who are unable to make an informed choice. This is based on the previous knowledge of the person, as there was limited information in the care files of resident’s dietary likes and dislikes. In one unit several people had be supported to eat their meal, and due to these demands, some people had to wait before they had their meal. Residents were encouraged to eat independently but due to demands on staff time some individuals did not receive the prompts they required to be able to do this. One resident was observed eating but then fell asleep into her food for a short period of time until a staff member came to her assistance. The variety of food provided is discussed regularly and this was evident from the minutes from the previous relatives and residents meeting. Grey Ferrers Nursing Home DS0000001907.V354926.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): National Minimum Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home responds to complaints according to a written procedure, and aims to protect people from harm. EVIDENCE: In response to the findings in the previous inspection report a considerable amount of work has been undertaken to work with the staff team and to implement systems, to improve the way both complaints and safeguarding adult issues are responded to. The residents and their relatives spoken to said that things have improved and that they have more confidence that they are listened to. The Registered manager now aims to attend at least one of the residents and relatives meetings on each unit so she is able to respond to any concerns directly and the minutes are displayed for all to access. The complaints procedure is displayed in every unit and in the reception area. This has not yet been updated to include the contact details for all of the external agencies that concerns can be referred to, but it was reported that the new format would be sent out soon. The contact details for the local office for the Commission for Social Care Inspection was also displayed but in one unit this did not include the telephone number. Staff spoken to had an awareness of how to respond to any concerns raised. The number of complaints received has reduced and it was reported that no complaints have been received since the last inspection, which was undertaken in July 2007. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 17 There were notices in the units to support that safeguarding adults training was planned and being delivered. This is an ongoing training programme to ensure all staff access this essential training, which is also part of the induction. There are systems in place to ensure any unexplained bruising is reported immediately to both the unit manager and the Registered manager who now receive a daily handover of this information from each unit. When examining the care files one file did contain a record of a body map which identified a bruise on the person. But this record was not dated, or signed and did not have any information recorded on it to support what action had been taken in response to this. It was reported that this might have been an old record since it did not contain this information, which is now current practice. It was reported that no safeguarding adults referrals have been made since the last inspection visit. Grey Ferrers Nursing Home DS0000001907.V354926.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): National Minimum Standards 19, and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, clean and well-maintained environment. EVIDENCE: The ‘expert by experience’ found Grey Ferrers to be a pleasant purpose built establishment, which was well laid out in adequate grounds with good footpaths between buildings and good parking. The garden areas were all well maintained. Feedback from residents and there relatives confirmed that each unit is well maintained and provided a comfortable environment. Residents stated that they were able to bring their personal possessions for their rooms, which were personalised in accordance with individual’s preferences. The expert by experience visited every bedroom on two units and found them to be attractive with no odours present. She felt the domestic staff worked Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 19 hard to keep the rooms fresh and clean. Communal areas were also found to be well maintained, clean, and furnished to reflect a homely environment. It was reported that some areas have had new furnishings fitted and the carpet identified for cleaning at the last inspection has been replaced. Grey Ferrers Nursing Home DS0000001907.V354926.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): National Minimum Standards 27, 28, 29, and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a competent staff team who have been recruited to ensure their well being is safeguarded. EVIDENCE: It was reported that there has been a high turnover of staff in the last few months and new staff have been appointed and are currently undertaking their induction and getting to know the residents. The staffing levels remain the same as what was identified in the last inspection report. Various comments were received about the staffing levels, as some relatives felt not enough staff was on duty whilst others felt it was satisfactory. The unit managers spoken to stated that they try and monitor the staffing levels based on the dependency needs of the residents. All staff are encouraged and supported to access level 2 of the National Vocational Qualification (NVQ). Due to the staff turnover this has resulted in a reduction to the percentage of staff that have achieved this training. It was reported that 40 of the staff team have now achieved this qualification, which is a good improvement since the last inspection. A further 15 staff members will be commencing this training on the next intake. Other training achievements this year, as outlined by staff, have been in relation to fire safety, safeguarding vulnerable adults and dementia. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 21 All new staff are assigned to a mentor who supports them through there induction period, and they work two supernumerary shifts to enable them to familiarise themselves with the environment. They receive an induction workbook that meets the skills for care specifications, and on completion of this they then complete the following work booklets: Health and safety, food hygiene, and understanding dementia. It was reported that all staff undertake fire and moving and handling training before they commence duties on a unit, and all staff spoken to confirmed this. There is a planned induction for all staff roles including the activities organisers, laundry staff and the qualified nurses. All induction packs include some form of training in dementia and this enables all staff to gain some skills and knowledge in this area. As a lot of staff have recently commenced employment at this home, they are in the process of undertaking all of the mandatory training but this is ongoing and will take up to six months to complete. Staff members spoken to were enthusiastic, motivated and committed to ensuring that people receive good quality care. The new staff members confirmed access to an induction, which they felt equips them with the skills and knowledge to fulfil their role. Staff felt supported by their colleagues and by the unit managers. Existing staff confirmed access to refresher training and service specific training such as tissue viability, and continence. It was reported that future training includes mental capacity act, mental health and challenging behaviour. Although staff have undertook a distance learning course in dementia comments from staff indicated that further training in this area would be beneficial The recruitment files for four staff members were examined and all were found to contain all of the documents and information as required by law. One application form did not contain a full employment history but this information was obtained during the inspection. Files contained evidence to support the training undertaken. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 31, 33, 35, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed to ensure that the health, safety and welfare of people and staff is promoted and protected. EVIDENCE: In response to the issues raised in the previous inspection report the management and the general running of this home has improved. New systems have been implemented in order to monitor practices and improve communication channels between each unit and the Registered manager. All of the staff have worked hard as a team in order to improve the general standards within each unit to ensure that both the delivery of care and the completion of documents are to a good standard and result in good outcomes for the residents. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 23 It was evident from the regulation 26 reports and the additional documentation seen, that the progress in achieving all elements within the action plan completed in response to the last inspection report, has been monitored and been a key focus during the visits undertaken. Systems are in place in order to consult and gain feedback from residents, and relatives through regular meetings and quality assurance surveys that are distributed on an annual basis. It was reported that surveys have recently been distributed. In response to the last inspection report the staff team have been sent surveys in order to gain feedback from their perspective. It was reported that this was a valuable exercise, which would be repeated. The comments received have been analysed and action has been taken in response to any learning outcomes. The Registered manager has regular meetings with the unit manager and heads of department in order to keep up to date with any issues and to ensure effective communication channels are maintained. Staff spoke favourably about the day-to day informal support provided by the management team and how ‘the office door is always open’. Unit managers also stated that they feel supported in their role both by their peers and the Registered manager. There was evidence in the staff files examined to support that regular supervision is provided both on a group basis and one to one, and staff members spoken to confirmed this. The systems for the management of residents’ money were assessed to be satisfactory at the last inspection and no changes have been made to the system in place therefore no further assessments was carried out on this occasion. It was reported that all health and safety risk assessments have been reviewed and signed off by the Registered manager. Information received before the inspection indicated that servicing of equipment and safety standards at the home were satisfactory and a sample examination of these supported this. All staff members spoken to was aware of the fire procedure and confirmed that regular drills and checks are undertaken. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP1 Good Practice Recommendations The results from the quality assurance surveys should be included in the Statement of Purpose. This will assure residents and relatives that their comments are listened to and enable perspective residents to gain an insight into living in this home. The monitoring of storage temperatures should be reviewed to ensure that medication is stored within the temperature range specified in the product licence. Information about medication in risk assessments and care plans should be reviewed to ensure there is sufficient detail to inform staff how to give correctly particularly when medication is to be given ‘when required’ or by specialised techniques. Where medication administration records are handwritten they should wherever possible be witnessed by a trained and competent person to ensure that they are correct. DS0000001907.V354926.R01.S.doc Version 5.2 Page 26 2. 3. OP9 OP9 4. OP9 Grey Ferrers Nursing Home 5. OP15 2. OP12 5. OP12 6. OP12 7. OP16 8. OP28 9. OP38 Residents preferences in relation to food should be obtained and the menus reviewed accordingly. This will ensure that people are offered a choice of meal each day that takes into account their collective preferences. Resident’s hobbies and interests should be recorded in their care files. This would enable staff to provide activities in accordance with individual’s preferences. Participation in activities should be recorded to support that their social needs are being met. Resident’s choices regarded preferred routines should be recorded in their care plans. This will assist staff to plan and in deliver care in a manner that meets resident’s preferences. The activity organisers should receive training specific to their role, taking into account the needs and preferences of people who use the service. This will enable the service provide a more person centred activity programme. The complaints process should be reviewed to include information about other agencies that people can raise their concerns with. This will ensure that people have the required information to take their concerns to an external agency if they are dissatisfied with the internal response. Progress should continue to ensure that 50 of care staff are qualified to National Vocational Qualification Level 2. This is to ensure that the staff have the necessary skills and knowledge to care for people using the service. Ongoing training should be provided to all staff to ensure they complete the required mandatory training and service specific training to enable them to fulfil their roles and responsibilities and meet individual needs. Grey Ferrers Nursing Home DS0000001907.V354926.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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