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Inspection on 20/09/05 for Grey Ferrers Nursing Home

Also see our care home review for Grey Ferrers Nursing Home for more information

This inspection was carried out on 20th September 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides specialist care in two units for residents with Dementia. One for nursing and one for residential/nursing care. The service has an excellent quality assurance system in place, which includes internal audits, regular meetings with management and the "Personal Best Programme" which BUPA have recently introduced.

What has improved since the last inspection?

With regard to Woodville and Brandon Units Only. Since the last inspection evidence was provided which demonstrated that dependency monitoring has improved A full independent pharmacy audit has been conducted to ensure compliance with Regulations, and company policy with regard to the administration of medicines. All service users are in the process of being reassessed on Brandon unit to ensure that needs are being met and where identified by professionals have been recategorised to receive nursing rather than residential care. Care plans; risk assessments and associated records were of a good standard and much improved particularly on Woodville unit. Woodville unit has appropriate sensory items in place including pictures and tactile items fitted around corridors and in bedrooms for the use of service users with Dementia.

What the care home could do better:

The outcomes for service users would be improved by: Ensuring that bedrail and falls risk assessments are evaluated appropriately and reflect the actual situation and are accurate in their detail. Ensuring that care plans are evaluated at least monthly. Ensuring that bank staff are fully aware of their professional responsibilities with regard to the administration of medicines. Ensuring that where professional decisions are made by nursing staff with regard to nutritional requirements that these decisions are fully supported by associated professionals such as social worker and/or dietician. Personal choices must be fully recorded in care plans and staff made aware of issues surrounding food choices. Ensuring that quality of food is monitored regularly by the registered manager. Ensuring that significant incidents are reported to the Commission for Social Care Inspection within given timescales. Ensuring that an adequate number of hoists are provided in each unit to meet service users needs (Brandon unit) Ensuring that unit managers have adequate supernumerary hours to complete managerial duties.Ensuring that when recruiting staff all appropriate checks are completed prior to contracts of employment being issued. Ensuring that policies and procedures relating to service users personal money are put in place and are updated to include the management of credit cards/cheque books and cash cards. Ensuring that risk assessments are appropriately updated after a service user has a fall or similar accident. Ensuring that fire safety is maintained by agreements with the fire department regarding the propping open of fire doors at night. The fire risk assessment must reflect the arrangements for maintaining safety where individual agreements are reached with relevant professionals. Ensuring that appropriate professionals are notified following a serious incident, which may require further investigation.

CARE HOMES FOR OLDER PEOPLE Grey Ferrers Nursing Home Priestly Road Off Blackmore Drive Leicester Leicestershire LE3 1LQ Lead Inspector Mrs Gillian Adkin Unannounced Inspection 20th September 2005 09:30 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.V249887.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grey Ferrers Nursing Home Address Priestly Road Off Blackmore Drive Leicester Leicestershire LE3 1LQ 0116 2470999 0116 2558364 allsoppm@bupa.com 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) BUPA Care Homes Limited Vacant 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.V249887.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. To able to admit named service user who falls within category MD(E) subjection of Variation No. 55305 dated 13 September 2003. Persons who fall within category DE(E) may only be admitted into Stewarts Hey & Woodville House Unit. Bradgate Unit may accommodate a total of 30 persons who fall within categories/combined categories OP and PD(E). Brandon House may accommodate a total of 30 persons who fall within categories/combined categories OP and PD(E). Service User Categories No person falling within either category OP or PD(E) may be admitted to the Home when an overall total of 60 persons who fall within those categories are already accommodated within the Home. To be able to admit the named person in category DE under 65 named in variation application numbered AN43335 dated 18/02/03. That the home is registered to admit on name Service User, named in application number V16985, under category TI That the home is registered to admit one named service user, in application number V22368 under category DE. 21.04.05 6. 7. 8. Date of last inspection Brief Description of the Service: Greyferrers 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. Brandon is occupied by older persons requiring residential/nursing care, Bradgate by older persons requiring nursing care, Stewards Hay and Woodville provide care for older persons with dementia. 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 provides nursing and residential care for service users whose care needs fall within the categories of Older Persons and or Physical Disability and Dementia over 65 years of age.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 the gardens. All bedrooms are single occupancy and all Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 5 are ensuite, many open directly onto the garden. The home is currently managed by a registered nurse and employs general nurses, mental health nurses and care staff. The home has ample parking and is close to a number of social amenities. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected for the eleventh time against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over one and a half days and commenced at 9.30 am on 20/09/05 and concluded on 21/09/05.The acting manager facilitated the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting three residents (two in Brandon unit and one in Woodville) and tracking the care they received through review of their records, discussion with them, and their relatives, care staff and observation of care practices. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. This inspection was conducted in Woodville unit and Brandon unit. During this inspection a tour of the accommodation (relating to service users tracked) took place and the inspector viewed internal records, and care plans. She also spoke to nurses, care and ancillary staff, residents (where practicable) and relatives. Discussions with the acting manager regarding requirements made at the last inspection (relating to Bradgate and Stewards Hay unit) indicated that three out of eleven requirements and most recommendations had been met. What the service does well: What has improved since the last inspection? Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 7 With regard to Woodville and Brandon Units Only. Since the last inspection evidence was provided which demonstrated that dependency monitoring has improved A full independent pharmacy audit has been conducted to ensure compliance with Regulations, and company policy with regard to the administration of medicines. All service users are in the process of being reassessed on Brandon unit to ensure that needs are being met and where identified by professionals have been recategorised to receive nursing rather than residential care. Care plans; risk assessments and associated records were of a good standard and much improved particularly on Woodville unit. Woodville unit has appropriate sensory items in place including pictures and tactile items fitted around corridors and in bedrooms for the use of service users with Dementia. What they could do better: The outcomes for service users would be improved by: Ensuring that bedrail and falls risk assessments are evaluated appropriately and reflect the actual situation and are accurate in their detail. Ensuring that care plans are evaluated at least monthly. Ensuring that bank staff are fully aware of their professional responsibilities with regard to the administration of medicines. Ensuring that where professional decisions are made by nursing staff with regard to nutritional requirements that these decisions are fully supported by associated professionals such as social worker and/or dietician. Personal choices must be fully recorded in care plans and staff made aware of issues surrounding food choices. Ensuring that quality of food is monitored regularly by the registered manager. Ensuring that significant incidents are reported to the Commission for Social Care Inspection within given timescales. Ensuring that an adequate number of hoists are provided in each unit to meet service users needs (Brandon unit) Ensuring that unit managers have adequate supernumerary hours to complete managerial duties. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 8 Ensuring that when recruiting staff all appropriate checks are completed prior to contracts of employment being issued. Ensuring that policies and procedures relating to service users personal money are put in place and are updated to include the management of credit cards/cheque books and cash cards. Ensuring that risk assessments are appropriately updated after a service user has a fall or similar accident. Ensuring that fire safety is maintained by agreements with the fire department regarding the propping open of fire doors at night. The fire risk assessment must reflect the arrangements for maintaining safety where individual agreements are reached with relevant professionals. Ensuring that appropriate professionals are notified following a serious incident, which may require further investigation. 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. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 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.V249887.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. 6. Appropriate assessment and risk management of service users ensures that needs are met and risks managed appropriately. EVIDENCE: All of the three service users case tracked had an initial assessment in place although on Brandon Unit these were not included into the care plan and were located in a secure cabinet. Falls, moving and handling and use of bedrails assessments were in place and in one instance included service user and relatives input however one assessment was found to be inaccurate and inconsistent with an associated falls risk assessment. All assessments in Woodville unit were found to be accurate and fully evaluated and representative of the current risks. No service users tracked were assessed as requiring Intermediate care. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 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): 7.8.9.10 Resident’s healthcare needs are met by the provision of an individual care plan. Outcomes would be improved by documentation of individual choices and better recording of actions/interventions and a safer system of administration of medicines. EVIDENCE: All of the three-service users case tracked had a plan of care in place. Care plans tracked identified health, social and personal care needs. Care plans tracked evidenced the involvement of external professionals involved in service users care. Evaluation of care plans was improved from the last inspection although it was noted that those in Brandon Unit still required more regular evaluation and were not in one case factually accurate. Individual risks had been appropriately assessed and reviews of care well evidenced however no evidence was found to suggest that any consultation had taken place with the service user or family. Most service users on Brandon unit are in the process of reviews by professionals in order to establish their current care needs status. Observation of practise, case tracking of two service users in Brandon Unit, and observation of an additional service users care plan indicated that privacy and dignity is not always observed. A service user was noted to be being Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 12 examined by the General Practitioner with the bedroom door open, another service user was noted to not be wearing any stockings; this was not evidenced as a personal choice in her care plan, although staff indicated that this was usual for her. A further service user was found seated in her room in night clothes at lunch time and noted to be eating food supplied by the family (tins of soup) although this was agreed within a care plan, nutritional issues associated with the service user had not been addressed with relevant professionals. The service user was noted to be at nutritional risk. Discussions with a member of bank staff indicated that she had recently returned to work on the unit after a long period of time and had been given a handover before commencing her shift, she informed the inspector that had attended to a service user (case tracked) and that she had found her to have soreness to which she had applied a cream. When questioned further it was indicated that the staff member had not checked medication records or signed them prior to applying the cream and on observation of the cream it was noted that it did not have a label and was not currently prescribed for this person. The inspector issued an immediate requirement notice. Medication records and associated blister packs relating to those service users tracked were inspected and found to be well managed and appropriately administered. Controlled drug stock was accurately recorded and accounted for. Other medication records were not inspected. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 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): 14.15 Giving residents’ choices over their daily lives and ensuring that they experience a homely life, which includes good quality meals and considers individual preferences ensures that the experience of living in the care home meets their specialist and individual needs. EVIDENCE: Discussions with one service user tracked indicated that mostly service users are given opportunities to exercise choice and control over their lives. Some evidence was found of service user consultation in care plans tracked although personal choices and end of life decisions were not fully documented. Other service users spoken with indicated that they are given the opportunity to express personal views at meetings however several stated that their views are not sought regarding quality of meals. A service user tracked in Woodville unit was unable to express personal views however key staff and named nurses demonstrated that despite service users illnesses they are treated respectfully and offered choices. Observation of the midday meals and discussion with service users, identified that a large number were unhappy with the quality of meals provided and the midday meal was described as chicken pie which was in fact a chicken casserole, potatoes were described by service users as lumpy, and without salt or butter. Discussions were held with staff and the Acting Manager regarding Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 14 personal food choices and the appropriate management and documentation of this. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 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): 16.17.18 Complaints are managed according to policy and responded to within given time scales. An adult protection procedure is in place and staff are confident in responding to suspicion or allegation of abuse. A more robust system of recruitment would ensure the protection of residents in the home. EVIDENCE: Discussions with service users and relatives during this inspection indicated that they were aware of the complaints procedure although two of the three service users tracked were unable to confirm their understanding. One service user tracked had no immediate relatives although a family representative advocated on her behalf and acted as her financial representative. Financial records relating to this person were examined and discussions with staff and the administrator demonstrated that the service users financial affairs were appropriately managed. Complaints records were inspected and indicated that all had been dealt with by the Interim manager during the manager post being filled. Policies and procedures relating to service user finances were not located on the units inspected although staff spoken with had a good understanding of service users individual financial situations. None of the service users tracked managed their own finances. Discussions with staff in relation to the management of adult protection demonstrated that all were aware of the companies whistle blowing policy and procedure. Training records identified that the most recent training held regarding adult abuse was during 2004 and therefore a number of staff including those recently appointed will not have undertaken yet. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 16 Four staff files inspected indicated that although the recruitment procedure was adequate a number of files did not evidence a POVA first check being obtained and several newly appointed international staff did not have CRBs in place, due to staff being appointed through an agency. Requirements were made that this is put in place immediately and responses will be dealt with by the Commission for Social Care Inspection under separate correspondence with the registered provider. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 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): 22.24 Clean, safe and well maintained living areas and bedrooms, which are personalised to reflect individual tastes, and provision of adequate equipment ensures that residents live in surroundings, which maximise independence and are comfortable and homely and are conducive with individual needs. EVIDENCE: Observation of care plans and inspection of service users rooms and equipment demonstrated that appropriate equipment is provided to meet service users needs and maintain safe practise. It was noted through observation of staff at work and by direct discussion that a significant number of service users require hoisting in both units and sufficient evidence was found by discussion with service users to indicate that their dignity was not being considered in relation to being able to visit the bathroom in an appropriate time due to the lack of hoisting equipment in Brandon unit. This had featured as a recommendation at the last inspection and it was indicated that a further hoist had been ordered but was not in use on this unit. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 18 Both units were noted to be clean and well maintained and appear to meet residents’ needs. Both are decorated and furnished to a good standard which creates a comfortable and homely environment. Plans are in place for refurbishment on Woodville unit this year and bedrooms are redecorated as they become vacant prior to a new resident moving in. There is an ongoing system of maintenance and refurbishment. The garden area is accessible to residents who are in wheelchairs Residents’ rooms are clean, well decorated and residents stated that they are able to bring items of their own furniture and possessions with them to personalise their rooms There is a spacious sitting room/ dining room on the ground in each unit and Woodville unit has a small conservatory. Rooms and corridors in this unit are Filled with an array of sensory equipment and materials. This unit has a calm and peaceful feel on entering. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 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): 27.28.29.30. Staff are provided with training opportunities and generally this training is put into practice to enable staff to competently meet the needs of residents. The strengthening of recruitment procedure would protect residents from potential harm or abuse. EVIDENCE: Staffing rosters were seen on both units and calculation of staffing hours indicated that both units were meeting minimum staffing hours as recommended by the previous registration authority. Recommended hours as detailed in the Department of Health’s Residential Forum considers the dependency of service users both units inspected have high dependency levels. When considering the recommended hours by the Forum both units have a deficit of approximately 24 care hours. Discussion with the acting manager indicated that both unit managers have individually identified the deficits and confirmed that staffing levels have been increased. Additional recruitment of staff is planned and a new staff nurse has been appointed to commence shortly. Bank staff are utilised to manage shift deficits. Further concerns had been identified by the acting manager (prior to the inspection) regarding the management of units and the difficulties associated with no supernumerary hours being factored into rosters. Staff files and training records indicate that recruitment practises require strengthening to ensure that all required documentation is in place this includes CRB disclosures and POVA first checks which must be put in place before employment commences. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 20 Training records inspected were not fully completed as the organisation has a new policy regarding the recording of staff training. The files are stored on the computer. Discussion with the ACM indicated that although BUPA have a rolling programme of training and induction for staff other training is sourced locally and delivered internally. Training delivered this year included Moving and handling, Tissue viability and infection control. Staff spoken with confirmed that they received all mandatory training including Fire. Health and safety. Moving and handling and NVQ. No obvious evidence was found to suggest that adult abuse/protection training had been delivered to staff this year. Two new staff discussed in detail their induction programme and what it had involved. BUPA has recently introduced training programme in Dementia Care, which is endorsed by the Rowntree Foundation, and the Alzheimer’s Society. Staff have not received the programme yet. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 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): 33.35.36.38 Service users financial interests are protected by a well-managed internal system. The health and safety and welfare of service users would be improved further by regular evaluation of risk assessments and robust follow up of accidents. EVIDENCE: The organisation has policies and procedures for the management of service users money. Several service users were spoken with including one case tracked and most stated that either they or a family member were responsible for financial matters or that money was deposited in the homes internal system. The inspector was able to look at records with the administrator all records are audited to ensure accuracy. The administrator stated that service users are issued with statements regularly to confirm the status of their account. These were seen for one service user case tracked. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 22 Two of the three service users tracked were unable to answer questions related to personal finances Evidence was seen of group supervision being held although it was evident from discussion with some staff that there was a need for individual sessions. The health and safety of service users is mostly protected by the systems in place. All records relating to health and safety including fire, accident and individual risk assessments were completed appropriately although concerns were raised with the ACMgr regarding the risk assessments of three service users in Brandon unit and in relation to the propping open of fire doors. The fire officer had undertaken an inspection visit recently and was expected to return to the home after this inspection to discuss an action plan. The fire risk assessment had been updated by the Interim manager but did not make reference to risks identified with propping open of fire doors. The manager stated she would discuss this with the fire officer on his next visit. Generic risk assessments were not inspected on this occasion but will be at the next inspection. The ACMgr was strongly reminded to ensure that generic assessments had been updated following an incident which resulted in an injury to a service user. Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 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 X 2 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 X X X 2 X 3 X X STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 3 X 1 Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? 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 2 Standard 9 3 Regulation 13(2) 17(1) a Sch 3 13(4) Requirement The registered provider must investigate the medication error as identified in Woodville unit. The registered provider must ensure that risk assessments for use of bedrails must be reflective of the current situation as identified during case tracking0 The registered provider must ensure that falls risk assessments are accurate and reflect the current situation and are evaluated at least monthly or as required according to risk. The registered provider must keep the service users plan under review. The registered provider must make suitable arrangements to ensure that the privacy and dignity of service users is respected The registered provider must ensure that where required service users nutritional needs/choices are supported by an appropriate assessment from a suitable professional and this is recorded in the service users DS0000001907.V249887.R01.S.doc Timescale for action 23/09/05 05/11/05 3 3 13(4) 05/11/05 4 5 7 10 15(2)b 12(4) 05/11/05 05/11/05 6 15 14.15 05/11/05 Grey Ferrers Nursing Home Version 5.0 Page 25 7 15 12(3) 8 18 12(1) 9 22 16(1)(2) 10 29 19 Schedule 2 11 38 13(4) 12 38 13(50 13 38 37(1)c care plan. The registered provider must so far as is possible take into account service users wishes and feelings regarding meals and food provided. The registered provider must ensure that the home makes proper provision for the welfare of service users and that where considered necessary incidents /accidents are reported to the appropriate authority for consideration under POVA guidelines. The registered provider must in accordance with the Statement of Purpose provide a suitable number of hoists in Brandon Unit according to the assessed needs of service users. The registered provider must ensure that the recruitment process is strengthened to ensure that all documentation as required in Schedule 2 including CRB, POVA 1st and leave to stay checks are completed and in place before employment is commenced. The registered provider must that all parts of the home to which service users have access is as far as practicable free from hazards to their safety. (Brandon unit) Generic risk assessments must be completed and evaluated at least quarterly. The registered provider must ensure that they provide a safe system of moving and handling service users and must ensure that risk assessments are evaluated after any MH accidents /incidents. The registered provider shall give notice to the Commission within 49 hours of any DS0000001907.V249887.R01.S.doc 05/11/05 05/11/05 05/11/05 05/11/05 05/11/05 05/11/05 05/11/05 Grey Ferrers Nursing Home Version 5.0 Page 26 14 38 23(4) a-d occurrence, which results in a serious injury to a service user. The registered provider shall after consultation with the fire authority take adequate precautions against the risk of fire 23/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard 3 15 27 35 Good Practice Recommendations The registered provider should ensure that all assessments and reviews of service users are stored in the care plan. The registered provider should consider reviewing the quality of meals provided by intermittent sampling of meals and discussion with service users. The registered provider is strongly recommended to factor in supernumerary hours to the unit managers schedule to ensure sufficient time to complete managerial duties. The registered provider is strongly recommended to include in policies and procedures and the service user guide the management of chequebooks, credit and cash cards. The registered provider is strongly recommended to ensure that where risk assessments include reference to the propping open of fire doors that appropriate reference is made to this monitoring in written records. 5 38 Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Grey Ferrers Nursing Home DS0000001907.V249887.R01.S.doc Version 5.0 Page 28 - 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. 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