Inspection on 21/11/07 for Grove Park Nursing Home

This inspection was carried out on 21st November 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

Grove Park Nursing Home 05/11/08

Grove Park Nursing Home 22/02/07

Grove Park Nursing Home 03/02/06

Grove Park Nursing Home 30/09/05

Grove Park Nursing Home 10/11/04

Grove Park Nursing Home 13/04/04

Grove Park Nursing Home 18/12/03

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

CARE HOMES FOR OLDER PEOPLE Grove Park Nursing Home 9 Plymouth Grove West Manchester M13 0AQ Lead Inspector Steve O`Connor Unannounced Inspection 21st November 2007 10:00 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 Grove Park Nursing Home DS0000021644.V355260.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. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove Park Nursing Home Address 9 Plymouth Grove West Manchester M13 0AQ 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) 0161 273 4557 0161 273 8456 gillespie170@aol.com Roja Limited Mr John Gillespie Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number disorder, excluding learning disability or of places dementia (20), Mental Disorder, excluding learning disability or dementia - over 65 years of age (20) Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users requiring nursing care by reason of mental disorder or dementia shall be 20 aged 50 years and over. Two named service users currently accommodated require nursing care by reason of mental disorder but are below 50 years of age. 22nd February 2007 Date of last inspection Brief Description of the Service: Grove Park Nursing Home is registered to provide nursing care for up to 20 residents, aged 50 years and over with a diagnosis of mental disorder or dementia. Grove Park is a large home that has been extended to improve accommodation and increase the number of single rooms available. Accommodation is situated over three floors and comprises of 18 single rooms and one double room. One single room has en-suite facilities and all other rooms have wash hand basin facilities. There is a smoking lounge, which is fitted with an electronic ventilation system and a lounge/dining room situated on the ground floor. There is a passenger lift to assist residents to their bedrooms on the first and second floors of the home. There are large garden areas and parking facilities at the front and rear of the property. The home is situated in Plymouth Grove West in the Longsight area of central Manchester close to local shops and amenities. The home is close to public transport routes to the City Centre and South Manchester areas. The fees, at the time of the inspection visit, ranged from £412 - £898 dependant on people’s individual needs. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was last inspected 22nd February 2007. This information included the home completing a self-assessment form called an Annual Quality Assurance Assessment (AQAA) describing how they feel they have supported people in meeting the National Minimum Standards. Additional information included incidents notified to the CSCI and information provided through other people and agencies, including concerns and complaints. Surveys were sent to people living at the home and to members of staff to find out their views of the service. Six people and seven members of staff returned surveys. During the inspection site visit time was spent observing how staff work with people and talking to management and staff on duty. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do in the future. What the service does well: What has improved since the last inspection? Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 6 Since the last inspection further work has been carried out to keep the decoration of the communal areas and people’s bedrooms up to a good standard and looking homely. The previous inspection report made a few recommendations for the owner to consider. It appeared that people’s benefit payments were being received on time and the financial recording of people’s personal monies had been updated. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 7 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 Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 8 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents were assessed prior to admission so that the management of the home could decide whether they could meet the person’s needs. EVIDENCE: The manager described the referral and assessment process. On receipt of a referral the manager would visits the prospective resident to carry out an assessment to determine if the home can meet their needs. Referrals were received mainly through local authority and Primary Care Trusts (PCT) who provided the home with a needs and risk assessments. Examples of these assessments were seen in people’s files that contained comprehensive information in relation to people’s emotional and mental health. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s general and mental health needs were known and people were supported to access the relevant services. The medication administration system did not fully protect people in making sure that they have taken the medication they require. EVIDENCE: Each person had an individual file and care plan based on the information gathered from the relevant assessments and knowledge of the person gained by staff at the home. The care plans concentrated primarily on people’s emotional and mental health, interventions to reduce risks and general health and personal care. The care plans contained very little information about non-clinical needs such as interests, relationships and preferred activities. As such it is recommended that care plans reflect a more person centred approach and include more Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 10 holistic needs and goals that are relevant and important to the person themselves. From talking to the manager and observing how staff work with people it was shown that the knowledge that staff have in how they work with and support people was not fully reflected within individual care plans and support interventions. It is recommended that care plans reflect more fully how staff actually support people to meet their needs and maintain their health and wellbeing. A care plan sampled showed good examples of risk assessments and clear and comprehensive support guidance and interventions to reduce risk. It was found that from the time that the actual risks first identified had reduced and the interventions used by staff were not the same as described in the risk assessment. Although care plans were reviewed on a monthly basis there was no evidence to show that the risk assessment had been reviewed and updated to reflect the current practice. It is recommended that changes in need, risk and the support provided be clearly reflected in updated care plans and risk assessments. It was found that risk assessments also focused on clinical issues around people’s mental health and behaviour. Issues such as finances, use of medication, use of alcohol and accessing the community were not addressed through the risk assessment process. It is recommended that the risk assessment process take into account people’s holistic needs. People’s files contained information about their mental and general health needs and also recorded the interventions from specialist and general health providers. The majority of people still had access and contact with local mental health services. The medication administration system was assessed and it was found that records of deliveries and returns were being maintained. A separate contractor was being used to dispose of medication. The medication administration records (MAR) were sampled and a number of errors were found. Several examples were found where staff had not signed for the administering of medication and the code system was being used without any description to explain why medication was not administered. An example was seen where medication appeared to be administered that did not follow the prescription information. Medication prescribed ‘as required’ (PRN) did not have any recorded administering guidance as to why and when the PRN medication should be given. The manager stated that there was an auditing and monitoring system but none of the errors identified had been explained or addressed. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 11 Requirements were made to ensure that the medication administration system was safe. Privacy for people sharing a bedroom was provided through curtain screens. All bedroom doors had privacy locks and people had their own bedroom key. Staff members were observed to treat people in a respectful manner. Interactions between staff and people were observed to be positive and respectful. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported to make choices and maintain control over their own daily routines and activities. EVIDENCE: Breakfast was served from around 8.00 am until 10.00, with people getting up at different times. Lunch was served 12.30 until 1.30, which was a light meal, soup and sandwiches. The main meal of the day was served around 5.30. Biscuits, scones and tea were provided at suppertime. Tea and coffee was available throughout the day. In addition to the main kitchen there was a small kitchen where staff could make people refreshments and light snacks. People commented on the surveys that they were happy with the meals and resident meetings were used to talk about the menu and what people wanted including or changing. The chef would regularly talk to people about their choice for meals and what they liked and disliked and any dietary needs. There were sufficient supplies of fresh food and meals were home-cooked. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 13 A number of people were independent in the community and came and went as they pleased according to their own preferences. Social and leisure activities were discussed at residents meetings and people made suggestions of what they would like to do. Although a number of suggestions were made for different activities there was no evidence that these suggestions had been acted upon. It is recommended that the residents meeting minutes record the actions to be taken to take forward people’s suggestions. A record of people’s individual activities was being maintained but this usually recorded health appointments. It had also been mentioned previously that people’s care plans and assessments contained very little information about their likes and dislikes and activities that they were interested in. A number of people had made a trip to Blackpool during the summer but no other trips had taken place. Several people were supported to visit local leisure amenities and a computer was available for people to use. Several people commented on the activities that they enjoyed, particularly when going out into the community and social evenings, such as karaoke. It is recommended that the social and leisure activities offered to people were recorded whether or not the person took the opportunity to participate. The home had an open policy for visitors, although preferred not to have visitors over mealtimes, unless prearranged. People’s religious needs were met through visits to the home by church members and people attending services at local places of worship. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Policies, procedures and staff practices should protect residents from abuse and protect their rights. EVIDENCE: The Complaint Procedure had been updated to include the current address of the CSCI. The procedure was made available to people and was on display. There was no evidence of any formal complaint made since the last inspection report in February 2007. Any informal concerns and worries that people raised would be dealt with by the staff at the time. Information from people suggested that they were aware of the complaint procedure and who they would speak to if they had any concerns. It is recommended that people’s concerns and worries and any action taken to change the situation for the person is recorded. The Adult Protection Policy and procedure set out the role of the management and staff in protecting people. The manager was aware of the process to follow in the event of an allegation or incident of abuse. A number of staff had attended a protection of Vulnerable Adults training event in October 2005. It is Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 15 recommended that all the staff team receive information and understand their role and responsibilities in reporting allegations and/or incidents of abuse. An Intervention Policy and general procedures around staff interventions as a result of verbal or physical interaction with people was in place and had been reviewed in February 2007. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises were safe, clean and offered enough space and flexibility to meet people’s needs but was in need of decoration in many areas. EVIDENCE: Accommodation was provided over three floors in a large detached house. The main kitchen, office, staff rooms, laundry facilities, and storage facilities were located in the basement of the house. On the ground floor there were two lounges, one for people who smoke, a dining room, small kitchen, toilets, shower room, bathrooms and bedrooms. Further bedrooms, bathrooms and toilets were located on the second and third floors. A lift provided access to the upper floors. Some bedrooms and communal areas, such as corridors, had been redecorated since the last inspection. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 17 A large number of residents smoked, and the smoking lounge was well used. Although ventilation was fairly efficient the decoration was heavily discoloured due to people smoking. There did not appear to be any plans for decoration of the smoking lounge. It was also seen that there were ongoing problems with burns to flooring in bathrooms, toilets and people’s bedrooms, which had to be frequently replaced. The flooring had been changed in the dining area / lounge with a hardwearing vinyl and was a comfortable environment. There was a TV and music players in both lounges. The manager highlighted that since the last inspection there had been severe water damage in several parts of the building due to poor roofing. The roof had been repaired and the water damage on ceilings and walls had been replastered. These areas had not yet been repainted or decorated and there were no set plans for this work to be completed. A plan with suitable timescales for action for the redecoration of the water damaged areas of the home must be provided to the CSCI within the timescale stated. Dedicated domestic staff undertook the majority of the cleaning and laundry tasks. They worked part-time hours and so the care staff would carry out any ad hoc cleaning and laundry duties outside those hours. The laundry facilities were sufficient to meet people’s needs. Staff had recently discussed the importance of infection control at the staff meeting in September as a result of an outbreak of diahoria and sickness that was caused by a virus. In a bathroom, disposable gloves were found but no disposable aprons. It was also found that shared bottled toiletries were being used and cloth towels were in use in bathrooms. The local Primary Care Trust Infection Control guidance recommends that all relevant safety equipment is made easily available outside of bathrooms and toilets rather than inside. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of appropriately qualified and experienced staff were employed to meet the needs of residents. EVIDENCE: The manager and deputy manager are both registered nurses and cover the management of the home across the week. The home has access to registered nurses who provide the nursing cover during the night, at weekends or if both the manager and deputy were not available. In addition, the staff team consists of three staff on duty between 8:00am and 2:00pm and two between 2:00pm and 8:00pm. There is two support staff on shift from 8:00pm to 8:00am. There is also a chef and three domestic staff who provide part-time cover during the whole week. Information provided by the home stated that out of 17 permanent care staff four had gained the NVQ Level 2 or above. A further three members of staff were undertaking a vocational qualification. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 19 Since the last inspection in February 2007 no new staff had been employed by the home. The previous inspection report had identified that all the required documentation and recruitment checks had been made. A log of the training that staff had undertaken showed that a range of core training had been identified. Staff surveys sent to the CSCI commented that they had received training to meet people’s needs. However, from the training log it was found that the only training staff had attended in 2007 was around fire awareness and that many of the staff had not appeared to receive training in emergency first aid, health and safety or adult protection. The manager stated that a lot of training, awareness raising and information sharing with staff occurred on an informal basis but there was no recorded evidence of this. It is recommended that all forms of staff training, awareness raising and information sharing that maintains and/or improves staff skills and knowledge be clearly evidenced and recorded. It is also recommended that a system be implemented that assesses the competence of staff to show that the knowledge and skills that they have acquired through training is being put into practice. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 20 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management, policies and procedures for the operation of the home were in place and worked in the best interests of people. EVIDENCE: The clinical manager was a registered nurse and stated that he had been in day-to-day charge of the home for the last three years. He had achieved the Registered Managers Award. The manager was part of the working rota and worked different shifts during the week. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 21 Another registered nurse is the deputy manager and provides the management cover when the manager is not on duty. At times both manager and deputy work overlapping shifts so that the manager can complete their operational management role. The manager is also available for staff to contact by phone. It was noted that previous inspection reports had highlighted that the owner of the care home was also the registered manager. These reports confirmed that the owner would nominate a person to apply to become the registered manager. However, this had not happened and the owner was still the registered manager even though they were not in day-to-day operational control of the home. The responsible individual must confirm to the CSCI who is the manager and, if required, make the relevant application to the CSCI to ensure that they are fit to be the registered manager. Previous inspection reports had identified and recommended that a more formal system of quality assurance be implemented to gain the views of relevant people to find out the quality of the service provided. Although residents meeting were held these looked at issues such as activities. Questionnaires were available for visiting professionals to complete but none had. The manager stated that they spoke to relatives and other professionals regarding the service but did not record any of this information. The recommendation was reiterated as a sign of good working practice. Information in relation to health and safety issues was gathered on site and via the AQAA provided by the home. Evidence was seen of the passenger lift and hoist being serviced, up-to-date gas and electrical equipment checks, water and legionella testing and a recent report from the local Environmental Health office that raised no issues. A recent fire risk assessment had been carried out that made a number of recommendations. The manager stated that these had been addressed. Visual checks were made of fire equipment, means of escape and the fire alarms were regularly checked. Fire drills were being carried out. The majority of people had their individual benefits paid into a single bank account. Although the inspector was told that this was an interest earning account and not connected with the running of the home there was no evidence to show how the interest was credited to individuals savings. A record was maintained of all the monies paid to people and of their spending on personal items. Each week money was withdrawn from the single account and this was used to purchase personal items such as clothes, cigarettes and beer. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 22 It appeared that the owner (and current registered manager) was the appointee for the majority of residents and it was being planned for the administrator to become the appointee for another recently arrived person. The National Minimum Standards highlights that people’s personal allowances should not be pooled and that it is recommended that the registered manager, or any other member of the home staff, are not the appointee for people and that, where possible, the purchasing local authority is contacted to transfer the appointeeship and individual personal monies to them. The manager had identified, with other relevant health staff, that a person was placing themselves at risk through taking control of their own finances. It was understood that placing restrictions on people’s access to money could only be agreed through the application of the Mental Capacity Act and the risk assessment process. It is recommended that people’s ability to manage their own personal finances be risk assessed taking into account the implementation of the Mental Capacity Act. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 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 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 3 Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 (2) Requirement The medication administration record must show clearly and accurately the administration, or otherwise, of all medication to prove that people are receiving the medication that they need. Medication prescribed ‘as required’ (PRN) must be accompanied with clear and sufficiently detailed administration guidance to ensure that staff know when and why PRN medication is given. Unless confirmed by the prescribing GP staff must follow the written administration details supplied with the relevant medication to ensure that the medication is given safely. 2 OP19 23(2)(b) and (d). A plan with suitable timescales 01/01/08 for action for the redecoration of the water damaged areas of the home must be provided to the CSCI within the timescale stated. Timescale for action 30/11/07 Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 25 3 OP31 8 (1)(b)(iii) The responsible individual must inform the CSCI of who is the manager of the home and make the relevant application to the CSCI to ensure that they are fit to be the registered manager. 01/12/07 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 OP7 Good Practice Recommendations It is recommended that care plans reflect a more person centred approach and include more holistic needs and goals that are relevant and important to the person themselves. It is recommended that care plans reflect more fully how staff actually support people to meet their needs and maintain their health and wellbeing. It is recommended that changes in need, risk and the support provided be clearly reflected in updated care plans and risk assessments. It is recommended that the risk assessment process take into account people’s holistic needs. 2 OP12 It is recommended that the residents’ meeting minutes record the actions to be taken to action people’s suggestions. It is recommended that the social and leisure activities offered to people are recorded whether or not the person took the opportunity to participate. 3 OP16 It is recommended that people’s concerns and worries and any action taken to change the situation for the person be recorded. Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 26 4 OP18 It is recommended that all the staff team receive information and understand their role and responsibilities in reporting allegations and/or incidents of abuse. It is recommended that local Primary Care Trust Infection Control guidance be followed in that all relevant safety equipment is made easily available outside of bathrooms and toilets rather than inside. It is recommended that all forms of staff training, awareness raising and information sharing that maintains and/or improves staff skills and knowledge be clearly evidenced and recorded. It is recommended that a system be implemented that assesses the competence of staff to show that the knowledge and skills that they have acquired through training is put into practice. 5 OP26 6 OP30 7. OP33 The registered person must ensure that a quality assurance system is in place that allows for the recording of consultations with the residents and their representatives. The National Minimum Standards highlights that people’s personal allowances should not be pooled and it is recommended that the registered manager, or any other member of the home staff, are not the appointee for people and that the purchasing local authority is contacted to transfer the appointeeship and individual personal monies to them. It is recommended that people’s ability to manage their own personal finances be risk assessed taking into account the implementation of the Mental Capacity Act. 8. OP35 Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Grove Park Nursing Home DS0000021644.V355260.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!