Inspection on 13/06/06 for Halwill Manor Nursing Home

This inspection was carried out on 13th June 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Halwill Manor Nursing Home 31/07/07

Halwill Manor Nursing Home 29/03/07

Halwill Manor Nursing Home 13/03/06

Halwill Manor Nursing Home 18/10/05

Halwill Manor Nursing Home 26/01/05

Halwill Manor Nursing Home 25/05/04

Halwill Manor Nursing Home 20/01/04

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

CARE HOMES FOR OLDER PEOPLE Halwill Manor Nursing Home Halwill Beaworthy North Devon EX21 5UH Lead Inspector Susan Taylor Unannounced Inspection 13th June 2006 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 Halwill Manor Nursing Home DS0000026717.V297181.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. Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Halwill Manor Nursing Home Address Halwill Beaworthy North Devon EX21 5UH 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) 01409 221233 01409 221265 Mrs Jacqueline I Mirjah Vacancy Care Home 25 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (13), Old age, not falling within any other category (25) Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Notice of Proposal to Grant Registration for staffing/environmental conditions of registration issued 5/8/1997 The maximum number of placements including that of the named individual, will remain at 25 To admit one named service user, named elsewhere, outside the categories of Registration as detailed in the Notice dated 4th August 2005.. 13th March 2006 Date of last inspection Brief Description of the Service: Halwill Manor is a privately owned care home registered to provide care for 25 patients. It is located in the heart of Halwill and has strong links with the local community. Halwill Manor is set back off the road and is situated in large and accessible grounds. Parking is provided and access to the home is level. The house is old and large, it has been adapted to suit the needs of people with mobility problems and care needs. There is a lift to help those with limited mobility access all floors. On the ground floor there is a large lounge and dining room; a smaller sitting area is adjacent to the main lounge off which are two offices. Two kitchens, a laundry, sluice room, staff rest room and some patient rooms are also on the ground floor. Home cooked meals are cooked on site. Activities and entertainment are arranged for patients. The atmosphere at Halwill Manor is relaxed and friendly yet professional. A qualified nurse is on duty to oversee the patients nursing needs 24 hours a day. The staff work hard to provide a homely environment whilst also striving to deliver quality care to Patients. Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key unannounced inspection, carried out on the 13th of June 2006 beginning at 9:30 a.m. lasting approximately 10 hours. The inspection included a full tour of the home and discussion with several staff including the provider, care staff, to registered nurses, the cook and maintenance person. The Inspector also spoke to a number of residents who offered their opinions on the food, the environment and staff who work at the home. At the same time, the Inspector observed care practices at staff delivered care to residents. What the service does well: What has improved since the last inspection? What they could do better: Recruitment practices are poor and would not ensure that suitable people care for residents’. An immediate requirement was made in respect of this. The provider was asked to locate files and take up references, including police checks (CRB and POVA) of named new staff by 16th June 2006. At the time of the inspection, Halwill Manor did not have a registered manager. However, since that time the Commission has registered a new manager. Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 6 Quality assurance measures need to be reported upon to the Commission and other people such as residents, relatives and social services departments. A requirement is made in respect of this. Residents and staff at Halwill Manor do not yet benefit from staff receiving regular supervision. A recommendation is made in respect of this. Shortfalls were evident in respect of the management of health and safety issues, which leave residents, staff and visitors at risk. An immediate requirement was made at the inspection about checks of the fire alarm, which the provider had to deal with the following day. 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. Halwill Manor Nursing Home DS0000026717.V297181.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 Halwill Manor Nursing Home DS0000026717.V297181.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home obtains comprehensive information about each resident prior to making a decision to offer them a place at the home. The needs of the service users are well known and met at Halwill Manor. EVIDENCE: The statement of purpose and service users guide provides prospective residents with a brief description of services provided at Halwill Manor. Four residents files were inspected - A statement of Terms and Conditions of residence was seen on all files. Nursing staff told the inspector that either the manager or registered provider assessed prospective residents prior to admission to ensure that their needs could be met at the home. Comprehensive assessments were seen on all the files and had been regularly reviewed. Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 9 Residents told the inspector that their needs were well met. Their comments included [ your doubt with] “ patience and love”. [ your dealt with] “ in a matter of minutes”. “ this is a wonderful place”. The Inspector observed kind and caring interactions between staff and residents. Specialist equipment was seen being used with some residents. The provider told the inspector that the home does not offer intermediate care. Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Halwill Manor has a good care planning process that provides clear information about the needs of the residents and how they are to be met. The home maintains good professional relationships with people external to the home to the benefit of the residents. Medicines are handled in a way that protects residents. Staff delivered care in a respectful way that maintains resident’s dignity. EVIDENCE: Four care files were inspected and had been regularly reviewed. Desired outcomes were clearly stated, providing achievable goals. Residents each had a nominated key worker whose responsibility it is to think that the care plans for current and the identified needs are met. Residents told the inspector that they were consulted about their care needs and therefore involved in the care planning process. Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 11 The inspector observed that a resident had bruising to right side of their face. This was discussion with the nurse in charge who told the inspector that the resident had sustained injury two weeks ago. The resident had been taken to hospital and treated there. Accident records show that appropriate action had been taken on 3/6/06 – observations had been recorded, the GP was called out and the resident was taken to hospital. Care records showed that risk assessments had been completed at the time of the individual’s admission to the home. These documented that resident had history of falls and osteoporosis and walked with Zimmer frame. A falls risk assessment had been completed and had been reviewed twice since admission. Additionally the resident’s care plan clearly identified the risk of falls and strategies for minimising this and had been reviewed twice since admission. The inspector saw evidence on residents files that verified that the home has a professional relationship with the general practitioner with whom all the residents are registered. In addition to this there are good links with the mental health and social services teams. This staff team were observed planning or providing care to residents in a manner that preserve their dignity such as in their own rooms or in an appropriate rooms such as the bathroom. A resident told the Inspector bells hardly ring here”. Residents also have their own clothing on that is laundered by the home. Care records demonstrated that consideration has been made about how residents prefer to be addressed and staff was seen to communicate with the residents by that name. The inspector observed a care assistant telling a resident “ you look very nice today”. Their approach was kind and caring. Coffee was being served according to residents needs. At the same time, the inspector observed a care assistant feeding a resident with drink mid-morning. They sat at eyelevel with the resident and enabled that person to drink at their own pace. Observed nurse administering medication during the evening. Good practice was seen. The inspector was told that two surgeries dispense medicines for residents. One of the trained staff is responsible for stock taking. Records of ordered drugs and a register of controlled drugs was seen. The nursing charge told the inspector that the system had been reviewed in respect of requirements made at an inspection in October 2005. The system was easy to audit Medication charts had been completed appropriately and had a photograph of the resident, their date of birth and GP surgery details. The inspector saw that medication was administered as prescribed. All medication was kept in a secure place. Halwill Manor Nursing Home DS0000026717.V297181.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Routines and activities are flexible and suited to individual residents needs. Residents are enabled to exercise choice and control over their lives whilst at the same time encouraged to maintain contact with friends and family in the community. Nutritional needs and personal preferences of residents are well met. EVIDENCE: The inspector had a discussion with four residents and was told that activities, food and links with the community are “very good”. An annual barbecue and fete is held at the home, usually in August, to which the local community is invited. A resident told the inspector that “ several go to the church opposite the home on a Sunday”. Another resident told the inspector that “ meetings used to happen here, but we are asked all the time if where happy”. The inspector saw that the home has plenty of resources and suitable equipment to allow them to vary the planned and spontaneous activities that happen at the home. Staff told the inspector that bingo and quiz sessions are held every week. Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 13 The evening meal was served during the inspection and consisted of cottage high, mixed vegetables and gravy. Residents verified that the cook knew what people liked and disliked and that they were offered an alternative if they did not wish to have the main course. Records of meals provided was seen, which verified that the home has a varied menu. The Cook told the inspector that roast dinners are cooked twice a week and they served food “ that they’re used to and like”. Liquidised meals was seen being prepared and looked appetising. In terms of quality assurance, the Cook told the inspector that waste was monitored and that she made time to seek verbal feedback from residents at mealtimes. The Inspector observed the care of one resident who was receiving nutritional supplements via a PEG feeding tube. Staff involved with this verified that they had received training to undertake this task. Halwill Manor Nursing Home DS0000026717.V297181.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Halwill Manors arrangements for the protection of vulnerable adults, including dealing with complaints generally ensure that residents are protected and able to voice their concerns. A bolt seen on the outside of bedroom door may potentially be used inappropriately to restrain residents and a requirement was made for this to be immediately removed. EVIDENCE: Halwill Manor has a complaints procedure that was displayed on the noticeboard. Additionally the complaints procedure is summarised in the ‘service users guide’. Residents who were spoken to during the inspection verified that if they did have a complaint it would be dealt with promptly by either the manager or provider. The inspector received no complaints during the inspection. Whilst touring the building the inspector saw that there was a bolt on the outside of bedroom door [room 14, first floor]. A care assistant told the inspector that it had been fitted a long time ago when a resident wandered but was no longer used. The inspector told the person in charge at the end of the inspection that the bolt must be removed to ensure that it was not used inappropriately to lock a resident in. The inspector saw a copy of the ‘Alerters Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 15 guide’ and whistleblowing policy. Residents comments included [ your doubt with] “ patience and love”. [ your dealt with] “ in a matter of minutes”. “ this is a wonderful place”. The Inspector observed kind and caring interactions between staff and residents. Staff spoken to had a clear understanding about recognising abusive practice and what steps they needed to take if they should witness an incident. The provider told the inspector that they and four other staff had attended recognised training on adult protection matters. Halwill Manor Nursing Home DS0000026717.V297181.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents at Halwill Manor live in a safe, comfortable and clean environment. EVIDENCE: A resident told the inspector that “local tradesmen are used” to carry out maintenance. At the same time, the resident said that “an electrician comes to do checks” and that maintenance to the lift had been done the previous week by a local contractor. The inspector toured the premises and saw that radiator guards were in place throughout the building. Fire exits were clear and accessible. Nearly all the bedrooms were inspected and found to be clean, individualised and comfortably furnished. All of the toilets and bathrooms had locks on the doors. A bolt on the outside of the door to bedroom 14 was seen. room 14 okay other than bolt on the outside of door. A care assistant told the inspector that it had been fitted a long time ago for a resident who had Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 17 wandered but was no longer used. A requirement is made in respect of this under the previous section. Hand towels and soap dispensers were seen in toilets, bathrooms and bedrooms. Good hand washing practices were observed as staff were seen to deliver care to residents. The laundry was clean and well organised. Infection control measures in respect of soiled linen were evident when the inspector spoke to staff about practices in the home. Sluices were clean and fully operational to allow the safe disposal of waste. Halwill Manor Nursing Home DS0000026717.V297181.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Care staff are in sufficient numbers to ensure that residents needs are well met. Recruitment practices at Halwill Manor are still poor and therefore fail to protect residents. The home has made good progress with training and development of staff, and this will ensure that competent and knowledgeable staff care for residents. The inspector is unable to make a balanced judgement about supervision practices in the home due to the fact that records could not be located. EVIDENCE: Duty rosters for the weeks starting 9th and 16th June 2006 were examined. These demonstrated that the manager works four out of seven days. The inspector saw that there was always five or six staff on duty in the morning, four or five in the afternoon and through into the evening. Additionally every day there is a cook and two domestics working 8am till 2:30 p.m. Maintenance is carried out by four people who cover five out of seven days a week. The provider has contracted 96 hours per week for maintenance of the home. There is a diverse staff team at Halwill Manor. A disabled member of staff has been recruited as part of the home’s drive towards equality and diversity. It was difficult to establish whether recruitment practices have improved since Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 19 the last inspection on the 13/3/06 because three out of four files selected could not be located. In addition to this one was chosen for a follow-up to establish whether references and CRB/certificate of good character had been obtained. In the case of the last file, a certificate of good character had been obtained since the last inspection. An immediate requirement was made with regard to recent recruitment practices in the home. The provider told the Inspector that she had “taken the her eye off the ball” and intended to address these issues immediately. This was further verified when the inspector selected further staff files and saw that previously appropriate checks had been taken for staff prior to their employment. Therefore the inspector agreed to extend timescales to enable the provider to meet the requirements in respect of individual staff concerned. Six staff were spoken to during the inspection. All of the staff verified that they had had manual handling training. In addition to this some of the staff had attended a dementia awareness training day. Care staff verified that training was regularly offered to them. Records also demonstrated that the professional development of nursing staff was encouraged to ensure that PREPP requirements are met. Certificates were seen on the files, which included infection control and wound management. Staff records examined showed that 3 x Carers had completed NVQ level 2, 2 x Carers – are doing NVQ level 2, 1 x Carer – has completed NVQ level 3, 1 x Carer – is doing level 3 and 1 x Carer – is doing the assessor’s award. The provider was unable to locate supervision records for the staff whose files had been examined. Halwill Manor Nursing Home DS0000026717.V297181.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 at least once during a 12 month period. 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. At the time of the inspection, Halwill Manor did not have a registered manager. However, the manager has since been registered. Some progress had been made towards the development of quality assurance systems in the home. It was evident that resident’s, staff and visitor’s views are respected in this home. However, the outcome of these measures need to be collated and reported upon to meet the current legal requirements. Overall, financial procedures safeguard residents’ interests. Residents and staff at Halwill Manor do not yet benefit from staff receiving an induction and regular supervision that has been recorded. Shortfalls were evident in respect of the management of health and safety issues, which leave residents, staff and visitors at risk. EVIDENCE: Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 21 The provider told the inspector that herself and the manager were in the process of doing the Registered Manager’s Award and hoped to complete it by the end of the year. An application for registration of the manager was in progress at the time of the inspection. In terms of quality assurance, the Cook told the inspector that waste was monitored and that she made time to seek verbal feedback from residents at mealtimes. A resident told the inspector that meetings used to be held with them but not recently. The same person said “ we are always asked informally whether were happy”. The provider told the Inspector that there was no formal quality assurance system. However, there was evidence of some auditing systems. An audit of health and safety had been carried out by a specialist company. Records showing how money is managed on behalf of residents were inspected. These were well kept, and accurately recorded the correct balance seen. Entries had been signed for. Receipts corresponded with entries for items such as chiropody, hairdressing and newspapers. Secure facilities are used to safeguard resident’s money. Three out of four staff files could not be located. No evidence was seen to demonstrate that new staff had received an induction that met national standards. Six staff told the inspector that they had been given an induction to the home. One person said “people work alongside senior staff”. In addition to this the provider told the inspector that they were unable to locate supervision records. The nurse in charge and six staff told the inspector that appraisals are conducted in the home. No records were seen that verified this. Comprehensive Health & Safety policies and procedures were seen, including a poster displayed near to the office. The poster did not state who in the home was responsible for day-to-day health and safety. A recommendation is made in respect of this. A member of the team was in process of doing a Health and Safety course to NEBOSH standards. Certificates verified that staff had attended infection control and manual handling training in the past 12 months. The inspector observed hand sanitizer being used by staff to minimise the risk of cross infection. Records of accidents were kept and showed that appropriate action had been taken. Fire drills, had taken place regularly. The fire alarm was last recorded as being checked on the 13/2/06 in the fire log. Residents spoken to during the inspection told the inspector that the alarm was checked regularly but could not recall when it was last checked. Similarly, staff told the inspector that the alarm had been checked but could not recall when it was last checked. An immediate requirement was made with regard to testing fire equipment at suitable intervals. Certificated evidence verified that the hoists had been regularly maintained. First aid equipment was clearly labelled. Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 22 Some of the staff on duty verified that they held a current first aid qualification. The health and safety file was examined. Clear policies and procedures were in place. Records of tests to electrical appliances and risk assessments had been recorded up to the end of 2004. Data sheets were seen. The provider told the inspector that an external specialist had audited health and safety practice in the home. The last report could not be located. The report for 2004 was seen on the file and highlighted the importance of training for a person responsible for health and safety matters. The provider told the inspector that her son was doing the course and will complete this in 2006. Halwill Manor Nursing Home DS0000026717.V297181.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 3 3 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 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 (1)(b)(i) Requirement The registered person shall not employ a person to work at the care home unless - subject to paragraph (6), (8), (9) her has obtained in respect of that person the information and documents specified in (i) paragraphs 1 to 9 of schedule 2. An immediate requirement was issued on 13/6/06 in relation to poor recruitment practices. 2. OP38 23(4)c(v) The registered person shall after consultation with the fire authority – (c) make arrangements (v) for reviewing fire precautions and testing fire equipment at suitable intervals. An immediate requirement was issued on 13/6/06 in relation to the checking of the fire alarm. 3 OP33 24(1,2) The registered person shall establish and maintain a system for evaluating the quality of the DS0000026717.V297181.R01.S.doc Timescale for action 16/06/06 16/06/06 31/01/07 Halwill Manor Nursing Home Version 5.2 Page 25 services provided at the care home. (2) At the request of the Commission, the registered person shall supply to it a report, based upon the system referred to in paragraph (1), which describes the extent to which, in the reasonable opinion of the registered person, the care home— (a) provides good quality services for service users; (b) takes the views of service users and their representatives into account in deciding— (i) what services to offer to them, and (ii) the manner in which such services are to be provided; and (b) has responded to recommendations made or requirements imposed by the Commission in relation to the care home over the period specified in the request. 4 OP18 13(6) This requirement is repeated from the last inspection report and relates to quality assurance processes that need further development. The registered person shall make 14/06/06 arrangements, by training staff DS0000026717.V297181.R01.S.doc Version 5.2 Page 26 Halwill Manor Nursing Home or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. This relates to the removal of a bolt on the outside of a bedroom door (No. 14), which the person in charge was asked to remove the following day. 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 OP36 Good Practice Recommendations The registered person should ensure that staff receive formal supervision at least 6 times a year. A record should be kept on each careworker/nurses file of these sessions. This recommendation is carried forward from the previous three inspection reports. Halwill Manor Nursing Home DS0000026717.V297181.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Halwill Manor Nursing Home DS0000026717.V297181.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. 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