Inspection on 11/09/06 for Harefield Nursing Centre

This inspection was carried out on 11th September 2006.

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

Other inspections for this house

Harefield Nursing Centre 25/06/07

Harefield Nursing Centre 08/05/06

Harefield Nursing Centre 14/11/05

Harefield Nursing Centre 25/04/05

Harefield Nursing Centre 05/10/04

Harefield Nursing Centre 15/04/04

Harefield Nursing Centre 10/09/03

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

CARE HOMES FOR OLDER PEOPLE Harefield Nursing Centre Hill End Road Harefield Middlesex UB9 6UX Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 11th September 2006 10:20 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 Harefield Nursing Centre DS0000010932.V311340.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. Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harefield Nursing Centre Address Hill End Road Harefield Middlesex UB9 6UX 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) 01895 825 750 01895 825 760 ANS Homes Limited Miss Eileen Louise Ward Care Home 40 Category(ies) of Dementia (13), Old age, not falling within any registration, with number other category (0) of places Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 40 ELDERLY FRAIL NURSING MINIMUM STAFFING NOTICE One service user, date of birth 16th August 1945 can be accommodated at the home, as agreed on 2nd April 2004. 8th May 2006 Date of last inspection Brief Description of the Service: The Harefield Nursing Centre is a purpose built home to accommodate 40 service users. It is situated in a semi-rural setting close to Harefield Hospital and Harefield Village and is served by public transport. The home was built in 1995 and all bedrooms are single occupancy with en suite facilities. The home consists of two floors with a lift. The first floor houses the kitchen, laundry and staff facilities and the ground floor is the living area for the service users. The home has recently carried out alterations to provide a secure unit now registered for 13 service users with dementia. The gardens are well maintained. Public transport in the form of Bus services is available in Harefield village and there are shops available in the village also. The fees charged range from £596.89 to £850. Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 15 hours was spent on the inspection process. A tour of the home was carried out, and service user plans, medication records, staff records, management records, administration records, maintenance and servicing records were viewed. 8 service users, 5 visitors and 11 staff were spoken with as part of the inspection process. The pre-inspection questionnaire given to the home at the time of inspection has also been used to inform this report. What the service does well: What has improved since the last inspection? The home had worked hard to address the requirements from the last inspection. The pre-admission assessments are comprehensive and clearly identify the needs of prospective service users. One section of the home has now been suitably adapted and registered as a separate unit for dementia care, and the staff had received dementia care training. Service users are being offered a choice at mealtimes and this choice is recorded. The timing of meals has also been reviewed to ensure adequate time between meals. There has been an improvement in the overall environment, and additional funds have been allocated to meet the refurbishment needs identified for the home. Bath and sluice rooms are no longer being used for general storage. Equipment is being maintained in working order, with prompt repairs being arranged as necessary. There is a marked improvement in the odour control within the home. The staffing has been reviewed and the home was being appropriately staffed at the time of inspection. The BUPA induction training has been introduced and new staff confirmed they were undertaking this training. Staff recruitment processes have improved. The home is being better managed, and in addition to the Registered Manager, the Deputy Manager is also supernumerary, allowing time for more effective management of clinical aspects to include supervision of staff and observation and review of care practice. The majority of staff spoken with said that communication between management and staff is good, and this shows an improvement in this area. Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 6 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. Harefield Nursing Centre DS0000010932.V311340.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 Harefield Nursing Centre DS0000010932.V311340.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 & 4. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some information about the service was out of date and thus did not give service users and their representatives the information they require to make an informed choice about the home. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. Staff had undertaken training in dementia care in order to provide them with the knowledge to care for service users’ specialist needs. EVIDENCE: Some of the copies of the Statement of Purpose and Service User Guide available contained out of date information. The documentation needs to be updated and copies provided for service users and their representatives. Prior to admission to the home, prospective service users are assessed to ascertain that the home is able to meet the service users needs. Pre-admission assessment documentation viewed had been clearly completed. Where available, copies of Social Services assessments are also obtained prior to admission. Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 9 The home now has been divided into a 13 bedded dementia care unit and a 27 bedded general nursing care unit. Appropriate alterations were made prior to the dementia care unit being registered, in order to provide a secure environment. Staff working on the unit had undertaken dementia care training to provide them with the knowledge to care for the service users, and the home has had input from the Consultant Psychiatrist for BUPA in developing the unit. Generally each unit has designated staff to provide continuity of care. Harefield Nursing Centre DS0000010932.V311340.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 adequate. This judgement has been made using available evidence including a visit to this service. Aspects of the service user plans were not always up to date, thus staff are not always provided with the current information when caring for service users. Medications are generally being well managed, however shortfalls identified could potentially place service users at risk. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: Six service user plans were viewed, two of which were in relation to wound care only. Generally these were up to date and gave a picture of the service user and their needs. Monthly reviews of the care plans had been carried out, but some of the information provided read like a daily report and not a monthly review. For one service user there had been no update of the service user plan following return from a hospital admission. Risk assessments for falls were in place and for service users who fall a falls diary document is put in place. For one service user this had been completed for 2 falls, whereas the daily record evidenced several falls. The need to ensure all documentation for falls tallies was discussed with the Deputy Manager. The Registered Manager carries out a monthly audit for falls. Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 11 Documentation for wound care was in place. Generally this was comprehensive and a separate care plan had been formulated for each wound, with photographs being taken. Consents for photography were available. Input from the Tissue Viability Nurse from Hillingdon PCT was clearly recorded. Where service users were refusing specific pressure relieving equipment or to comply with the care required to minimise the risk of developing wounds, then this had been clearly recorded. Assessments for nutrition, pressure sore risk, moving & handling and continence were in place, and care plans formulated. Some of the assessments were not being reviewed monthly, and the need to ensure all documentation is up to date was discussed. There is a document for the recording of service users monthly weight, and in some instances this had not been completed. A separate book of weights was available, however the need to ensure the need to ensure this information is transferred onto each service users individual record was discussed. Care charts are in place for service users with high dependency needs, and these are completed each time care intervention is provided. There was evidence of input from the GP and other healthcare professionals. The clinical room was clean and tidy and action had been taken to clean the clinical storeroom on the first floor. Medications are securely stored in the home. The room temperature had been recorded as above 25˚ centigrade, with it regularly being between 27-31˚ centigrade. Air conditioning needs to be installed to maintain the room temperature below 25˚ centigrade. The medications fridge temperatures were within safe range. A minimum/maximum fridge temperature thermometer is in use, but the minimum and maximum temperatures were not being recorded, and this needs to be addressed. Liquid medications had been dated when opened. Variable doses of medications were being clearly recorded. A stock check was carried out for a sample of medications and stocks and records were accurate and up to date. All receipts, administration and disposal of medications are recorded. Medications requiring refrigeration were being correctly stored. Two controlled drug records checked showed a discrepancy between the recording and the actual number of tablets in stock. Following the inspection the Deputy Manager has carried out an investigation into this finding and identified shortfalls in practice. Additional medication training is being arranged for the staff involved. In light of the findings, additional controlled drug records and stocks were checked and no further shortfalls were identified. Single use lancets are provided for blood glucose monitoring. The BUPA medications policy in place did not accurately reflect the monitored dosage system in place, and this needs to be reviewed. Staff were seen caring for service users in a professional, courteous and sensitive manner, and service users and visitors spoken with were very satisfied with the care provided at the home. Staff were observed knocking on bedroom doors and awaiting an answer before entering. Service users clothing Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 12 is individually labelled. Service users can bring in personal possessions in line with fire safety. Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & aspects of 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity input for the home is quite general, and the activities programme does not reflect provision for service users individual interests and specialist needs. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: The home has an activities co-ordinator. She stated that she has attended dementia care training to give her the skills to also provide activities for service users with dementia. There is a monthly activities programme, but this only gives an overview of the activity for each weekday. It is important that an activities programme be formulated in conjunction with the interests and capabilities of the service users. Separate programmes should be available for each unit, with morning and afternoon sessions being specifically planned to meet the needs of service users on each unit. The activities co-ordinator stated that she did not have money provided for activities, but provision for this is included in the budget for the home. Service users spoken with said that they did have some activities, but that they would like more provided. Some of the Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 14 service user plans contained information regarding service users interests and hobbies, and this information needs to be gathered for all service users, in order for the activities programme to be effectively planned to meet their needs. The home has an open visiting policy and visitors spoken with said that they are made very welcome at the home. Representatives said that they are kept informed of any issues noted with their loved one. Service users can receive visitors in the communal areas or in the privacy of their own bedrooms. The home has information available for Hillingdon Age Concern advocacy services. There is also information displayed for the Hillingdon Homes group who hold regular meetings for representatives to attend and discuss any general issues. Service users spoken with said that they are offered a choice of meals, both for the lunch and suppertime meals, with a cooked option also available for breakfast if they so wish. Kitchen records showed that choices are being recorded. Overall service users spoken with expressed their satisfaction with the food provision at the home. The daily menu reflected the meals being provided on the day of inspection. The timing of the evening meal has been reviewed to commence at 5pm, allowing more time between the lunch and supper meals. Kitchen records to include temperature records for food, fridges and freezers, plus cleaning schedules, were up to date. Safe working practice information was on display. Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. Procedures for the protection of vulnerable adults are in place, but staff training in this area needs to be progressed for the effective safeguarding of service users. EVIDENCE: The complaints log was viewed and all complaints received had been recorded, investigated and outcomes detailed. There is a monthly monitoring of complaints received by the home and by the Registered Provider. The complaints procedure on display required review to include updated CSCI contact details for the area and this was discussed with the administrator. The home has policies and procedures in place for safeguarding adults, and these dovetail with the Hillingdon Safeguarding Adults documentation. There have been no POVA issues since the last inspection. Staff spoken with said that they would report any concerns. The training matrix showed that in 2006 very few staff had received POVA training and this needs to be addressed. Harefield Nursing Centre DS0000010932.V311340.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): 19, 20, 21, 22 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Redecoration and refurbishment has taken place and is ongoing to maintain an attractive and safe environment for service users to live in. The communal space provision is good, providing service users with areas to sit and socialise with other service users, staff and visitors. Equipment and storage facilities are available to meet the needs of the service users and the home. Bedrooms are personalised, thus providing service users with a homely environment to live in. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: One Inspector carried out a tour of the premises. Since the last inspection one section of the home has been registered as a dementia care unit. Overall the home was being well maintained. The garden looked well tended and there is now a separate enclosed safe area for the service users on the dementia care unit. The Operations Manager for the home stated that funding had been made Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 17 available for the areas of refurbishment required in the home. Progress with refurbishment will be reviewed at the next inspection. The dementia care unit has a main lounge plus a quiet room for service users to use. There is also an enclosed garden area for them to access. The general nursing unit has a spacious sitting room and a dining room for service users to use. There is also access to the garden area for service users and their visitors. The assisted bath and shower facilities throughout the home were clean and tidy. Sluice rooms were also clean and generally tidy, and were no longer being used as storage areas. The moving & handling equipment in the home was in working order, and was appropriate to meet the service users needs. Rails are available in the corridors and also in the bath, shower and en suite facilities as required. Since the last inspection action has been taken to ensure any bedrails in use in the home are compatible with the bed they are attached to, and no issues were noted in the rooms viewed on this occasion. It was noted that generally staff were available to answer call bells promptly, and no concerns were raised by service users or visitors. The laundry room was clean and tidy. Recruitment had taken place and several new staff had been employed for laundry and domestic duties. Overall the home was clean and tidy, and smelled fresh. In isolated areas where an odour was noted the Domestic Supervisor was aware of this and action is being taken to replace carpets where a need has been identified. Harefield Nursing Centre DS0000010932.V311340.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 adequate. This judgement has been made using available evidence including a visit to this service. The home was appropriately staffed to meet the needs of the service users. Staff have received appropriate induction training to provide them with the basic skills and knowledge to meet the needs of the service users, however recognised training in care had not been commenced, and staff therefore are not being kept up to date with current good practice. Robust recruitment and vetting procedures are in place, thus safeguarding service users. EVIDENCE: The 2 units are being separately staffed. On the morning of inspection there was one registered nurse and 3 care staff on the dementia care unit, and one registered nurse and 5 care staff on the general nursing unit. Staff and visitors had noted an improvement in the staffing provision over the last few months, and BUPA had undergone a recruitment drive to address the shortages previously identified. The ancillary staff provision has also been reviewed and staff recruited to provide appropriate levels of staff to meet the cleaning, laundry and kitchen needs of the home. Arrangements for providing cover for maintenance in the home were in place. The home has accessed NVQ in care training with several staff now registered to undertake level 2, although the training had not been commenced at the time of inspection. BUPA are corporately aware of the need for 50 of all care staff to be qualified to NVQ level 2 or above, and this needs to be progressed. Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 19 The Registered Manager has confirmed that 4 care staff are qualified to NVQ level 2 in care or the equivalent, this being a total of 20 of the care staff. Three sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001, with the exception of one photograph, which was being addressed. BUPA has a 12 week induction programme that meets the Skills for Care core standards. New staff spoken with said that they were in the process of completing this training, and some had attended another BUPA home as part of the induction process. There was evidence of some staff had received periodic training in topics relevant to the needs of service users. All staff must be kept up to date with training to ensure they have the knowledge and skills to meet the service users needs. Harefield Nursing Centre DS0000010932.V311340.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): 31, 33, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home. Systems for quality assurance are in place, thus providing an ongoing process of system and practice review. Staff supervision sessions need to be carried out at regular intervals, to provide a forum for individual discussion and reflection on practice. Systems for the management of health and safety are in place, however shortfalls identified could potentially place service users, staff and visitors at risk. EVIDENCE: The Registered Manager is a first level registered nurse with a qualification in management, NVQ level 4 equivalent. The Registered Manager was on leave on the day of inspection. The majority of the staff spoken with said that the Registered Manager is approachable and supportive. A few staff did comment Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 21 that they did not always feel that all staff are equally managed and valued, and this has been discussed in general terms with the Registered Manager. Since the last inspection the home has received a lot of input and support from BUPA, to include regular monitoring by the Quality Manager. As part of the quality review there had also been regular input from the BUPA Tissue Viability Nurse Specialist. Regulation 26 visits take place monthly and a copy of the report is forwarded to CSCI. Monthly audits take place to include medication, accidents and complaints. The Operations Manager stated that proportional staff surveys are being introduced. The merit of gaining a good overview by offering all staff copies of the questionnaire in the first instance was discussed. The home is in the process of introducing BUPA’s customer satisfaction survey. The home is also introducing the BUPA ‘Personal Best’ training for all staff, which develops staff in all areas of customer care. The home produces a monthly newsletter and copies of this were available on each unit. Minutes of service user and representatives meetings were available. There was evidence of some staff meetings taking place infrequently. The management of service users monies was viewed at the last inspection and found to be satisfactory. The administrator was not present so Standard 35 was not viewed at this inspection. Supervision records did not evidence that all staff providing care are receiving supervision a minimum of 6 times per year, and this needs to be addressed to provide a forum for individual discussion and reflection on practice. Servicing and maintenance records were sampled and those viewed were up to date. The staff training matrix was available and showed that not all staff had completed up to date health & safety training to include moving & handling and fire safety. Other training undertaken included food hygiene and infection control training, both done via distance learning courses. Risk assessments for COSHH and safety data sheets were available in the laundry. Risk assessments for safe working practices are available for all areas of the home. Copies of those for the equipment in the laundry & kitchen had not yet been provided in these areas. Staff spoken with said that they had received health & safety training to include moving & handling and fire safety. The last recorded fire drill was dated 12/04/06. Fire drills must be conducted regularly to ensure all day and all night staff participate in fire drills at the required intervals. Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 3 3 3 3 X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 2 Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 6 Requirement The Statement of Purpose and Service User Guide must be kept up to date. Copies must be forwarded to CSCI. Service user plans must be kept up to date and provide an accurate picture of the service users condition and needs. Falls risk assessments must be in place for each service user. These must be updated regularly and following any falls. (timescale 01/06/06 not met) Service user plans to include the assessments must be reviewed monthly and whenever a service users condition changes. The room temperature in the clinic room must not exceed 25˚centigrade. Action must be taken to address this finding. Minimum and maximum fridge temperatures must be recorded along with the actual fridge temperature. Staff must at all times follow correct procedures for the administration of medications. DS0000010932.V311340.R01.S.doc Timescale for action 01/11/06 2. OP7 17 01/10/06 3. OP7 13(4) 01/10/06 4. OP8 17 01/10/06 5. OP9 13(2) 01/12/06 6. OP9 13(2) 01/10/06 7. OP9 13(2) 11/09/06 Harefield Nursing Centre Version 5.2 Page 24 8. OP9 13(2) 9. OP12 16(2)(m) (n) 10. 11. OP18 OP28 13(6) 18(1) 12. OP30 18(1) 13. OP36 18(2) 14. OP38 18 15. OP38 23(4) The homes medication policy must be relevant to the monitored dosage system for medications in use in the home. There must be an activities programme in place to reflect appropriate activity provision in and outside of the home, which suits the needs, preferences and capacities of each group of service users. All staff must receive training in the protection of vulnerable adults. 50 of care staff must be trained to NVQ level 2 in care or the equivalent. An action plan with timescales must be formulated to evidence how this will be achieved. There must be evidence that staff have undertaken training and updates in clinical topics relevant to the service users needs. All staff providing care must receive formal supervision a minimum of 6 times per year. An action plan to address this must be drawn up. Staff must undergo health & safety training and updates at intervals in line with current legislation and guidance. Fire drills must be carried out at the required intervals. There must be evidence that all staff have undertaken fire drills at the required intervals, a minimum of 6 monthly for all day staff and 3 monthly for all night staff. An action plan to address this must be put in place. 01/10/06 06/10/06 01/12/06 01/11/06 01/11/06 01/11/06 01/11/06 01/12/06 Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP33 OP38 Good Practice Recommendations It is strongly recommended that staff meetings take place on a regular basis. It is strongly recommended that copies of the risk assessments for the kitchen and laundry equipment be made available in theses areas. Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Harefield Nursing Centre DS0000010932.V311340.R01.S.doc Version 5.2 Page 27 - 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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