Inspection on 25/06/07 for Harefield Nursing Centre

This inspection was carried out on 25th June 2007.

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

The inspector 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 11/09/06

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 Clare Henderson-Roe Key Unannounced Inspection 25th June 2007 10:50 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.V336412.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.V336412.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 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.V336412.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. 5th February 2007 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 carried out alterations to provide a secure unit registered for 13 service users living with the experience of dementia. The 27 bedded unit provides general nursing care. 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 £603 to £950. Harefield Nursing Centre DS0000010932.V336412.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 16 hours was spent on the inspection process. The Inspectors carried out a tour of the home, and service user plans, medication records, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 12 residents, 12 staff and 4 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment document completed by the home and comment cards from service users and representatives/visitors have also been used to inform this report. What the service does well: What has improved since the last inspection? The Manager Designate has been in post for 6 months and has worked hard to improve the standards at the home. Teamwork and morale among the staff is much better and staff spoken with said that the Manager Designate is very approachable and they feel supported by the home management. The Statement of Purpose has been reviewed to provide up to date information about the services offered by the home. There has been a good improvement in the formulation and review of the service user plans and these now provide a clear picture of each persons needs and how these are to be met. There has also been a good improvement in the management of medications, which are now being well managed throughout. There has been an improvement in the Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 6 activities provision and a new activities co-ordinator with a wealth of experience in this field has been recruited. Staff have received training in POVA and those spoken with were clear that they would report any concerns. The Manager Designate has identified the training needs for the home to include the need for more staff with NVQ in care level 2 & 3 qualifications and has taken action to start to address this. Staff now receive formal supervision regularly. Training and updates for staff in topics relevant to the needs of the residents plus health & safety subjects have taken place with further training planned. 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. Harefield Nursing Centre DS0000010932.V336412.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.V336412.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): 1 & 3. 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. The Statement of Purpose has been updated to provide an accurate picture of the services provided by the home. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The Manager Designate said that the Statement of Purpose had been fully updated and a copy has been forwarded to CSCI. Representatives spoken with said that they had been provided with written information about the services provided by the home to visiting it. Prospective residents are fully assessed prior to admission to ascertain if the home is able to meet their needs, and an example of an assessment was viewed, which had been fully completed. The home also obtains copies of the Social Services needs led assessment for each person. Harefield Nursing Centre DS0000010932.V336412.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, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plan documentation is comprehensive and up to date, thus providing staff with the information to meet each resident’s individual needs. The home has input from healthcare professionals and medications are well managed, thus ensuring the health care needs of residents are being met. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. Resident choices regarding end of life care are recorded, thus ensuring that individual wishes are respected. EVIDENCE: 4 service user plans were viewed as part of the inspection process. These were up to date and provided a good picture of each persons needs and how these were to be met. There was evidence of monthly reviews taking place. Risk assessments for falls were in place and also a falls monitoring diary is completed each time someone falls. One falls risk assessment was updated at the time of inspection and all others viewed were up to date. There was no evidence of involvement from residents and representatives with the exception of some assessments and/or consents being signed. The Manager Designate Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 10 explained that BUPA are introducing new, comprehensive service user plan documentation to the home in July 2007 and the assessment and review process for each resident will involve both the individual and their representative. Prior to the implementation all nurses and care staff will receive training on how to complete it. Assessments for moving & handling, nutrition, pressure sore risk and continence had been completed and were up to date. Associated care plan documentation was also in place. For residents with wounds a separate care plan had been formulated for each wound and it was easy to follow the progress of each wound. From viewing the wound documentation it was clear that the home was having good success with improving and healing wounds. Pressure relieving equipment was in use in the home and the Manager Designate had a complete list of the equipment in use for each individual. The Inspectors recommended that this information also be written on the care plan. Risk assessments for bedrails had been completed and in most cases the consent for their use had been signed. For one person without a next of kin this was to be addressed and this was discussed with the Manager Designate. Monthly observations to include weights are carried out and any marked changes are referred to the GP. There was evidence of input from healthcare professionals to include GP, chiropodist, optician and tissue viability nurse. The home also has access to a Consultant Psychiatrist and Tissue Viability specialist employed by BUPA. One Inspector viewed the medication management for the home. All receipts, administration and disposals had been clearly recorded, and the correct method of disposal was in use. The Deputy Manager manages all medication disposals for the home. Several of the medication administration records were viewed and were complete and up to date. The home uses a monitored dosage system and the morning blister packs were viewed and stock control was good. One coding being used had not been defined and this was discussed and addressed at the time of inspection. For one resident whose medication had been increased in line with the GP instructions this was clearly recorded and implemented. Controlled drugs records were up to date and the register was being completed correctly. Stocks were checked and correct. Medications are being securely stored in the home. Professional use lancets are in use for blood glucose monitoring. All prescribed creams are securely stored. For one resident being fed via a percutaneous endoscopic gastrostomy tube this had been clearly recorded. The fridge temperatures were within safe range, however there is still an issue with the clinical room temperatures that are regularly over 25° centigrade, and this is a repeat finding. The home has policies and procedures in place for the management of medications and copies are available on the medication trolleys. The medications are being well managed at the home. Staff were seen caring for residents in a gentle, caring and professional manner. Staff were being especially patient with residents living with the Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 11 experience of dementia. Each bedroom has a telephone extension for receiving incoming calls and residents can choose to have their own private telephone if they so wish. Staff were heard calling residents by their preferred term of address. Clothing is labelled and residents were well dressed, expressing individuality. On the day of inspection a local priest had been visiting and peoples religious views are recorded and respected. Bedrooms were personalised and residents are encouraged to bring in personal possessions in line with fire safety. The service user plans contained information regarding individual wishes in respect of health deterioration and end of life care. The Manager Designate said that she is intending to introduce the Liverpool Care Pathway, which relates to end of life care. Where possible information is ascertained at the time of admission, however if people do not wish to discuss this sensitive topic then it can be done at a later date. Policies and procedures for the care of the dying are in place. The home receives input from the Macmillan palliative nursing team. Harefield Nursing Centre DS0000010932.V336412.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provision is good and information regarding individuals’ hobbies and interests is obtained, thus enabling the activities co-ordinator to plan a programme to reflect these wherever possible. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was available, thus peoples right to individual representation is respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: Since the last inspection the home has a new activities co-ordinator who works 24 hours per week. One Inspector spoke with her and it was clear that she has extensive experience in the provision of activities for older people to include those with dementia care needs. An activities programme was on display and there was evidence of outings having taken place and more being planned. Residents spoken with expressed their enjoyment with activities and especially outings. There is a photograph album in the foyer with pictures of the various activities that have taken place. Care plans are in place for individuals hobbies and interests, plus a ‘map of life’ to provide staff with information about each persons life history. The home now has a cat on the dementia care unit. Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and offered refreshments. Residents can choose to receive visitors in their own bedroom or in one of the communal rooms, whichever they so wish. The Manager Designate explained that for any prospective resident who does not have a representative, an advocate to act on the residents’ behalf is arranged by the placing authority prior to the persons admission to the home. The home has contact details for Age Concern advocacy services. The Manager Designate was very clear about the importance of ensuring all residents have someone who can effectively advocate on their behalf if they are unable to do so for themselves. One Inspector viewed the kitchen and it was clean and tidy. There was a good supply of foodstuffs and all items viewed were in date. Residents spoken with were generally satisfied with the food provision. It was clear that there had been some recent issues with the meals and the Manager Designate was aware of this and had also received comment from residents following a satisfaction survey. The weekend cook is now working more days, her standard of food provision is good and the residents like the meals now provided. The Manager Designate explained that until a new full time cook is recruited she is aiming to have continuity of bank and agency catering staff to ensure that all duties to include associated records are fulfilled correctly. The menu was on display and residents said that they are offered a choice. The lunchtime meal is now conducted at one sitting and one Inspector viewed the lunchtime and this was a sociable occasion with staff available to assist residents as necessary. Condiments and various sauces were available on the tables. Staff were serving people individually and the Manager Designate is wanting to implement further ‘fine dining’ improvements for mealtimes. Harefield Nursing Centre DS0000010932.V336412.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the residents. EVIDENCE: The home has a clear complaints procedure with timescales for completion. There have been 5 complaints since the last inspection and all concerns raised are recorded and fully investigated and responded to. There is a detailed complaints log maintained with outcomes recorded. BUPA has a monthly audit of all complaints and all complaints are monitored. Residents and visitors spoken with said that any issues raised are promptly addressed. Staff spoken with said that they had received training in safeguarding adults and those questioned were clear that they would report any concerns of this nature. There have been no POVA issues since the last inspection. The home has policies and procedures for POVA in place and also follows the Hillingdon Safeguarding Adults procedures. Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 15 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): 19, 21 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the home is being well maintained, thus providing a clean and homely environment for residents to live in. Some attention to the bathing facilities is required to fully meet resident needs and preferences in this area. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: Since the last inspection the Dementia Care Unit has been redecorated and refurbished, to include furnishings, carpets and lino flooring for the dining and quiet lounge areas. There is a redecoration and refurbishment plan in place, with evidence that there has been ongoing redecoration of various areas of the home. Plans are in place to install CCTV to the external of the premises following security concerns. The grounds are well maintained and there are raised flowerbeds that residents can tend to, and therefore be involved in a hobby they enjoy. Plans are also in place to plant a sensory garden and also Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 16 set up a sensory room, both for the dementia care unit. The Manager Designate is aware that 13 of the beds are still divan and need to be replaced with adjustable beds and said that this would be budgeted for on a rolling programme. The grouting in the shower room on the general nursing unit was very marked and needs replacing. One bathroom is never used due to the bath provision and it was agreed that this could be converted to a ‘wet room’ to better meet the residents needs and preferences. The bedrooms have en suite facilities to include a wash hand basin and toilet, plus there are toilets situated near the communal rooms. One Inspector viewed the laundry room. This was clean and tidy and items viewed were labelled. There are two washing machines, both with a sluice wash facility to manage soiled and infected laundry. There are also two tumble dryers, a rotary iron and a standard iron and board. The instruction booklets for all equipment were available in the laundry. The laundry person was clear about caring for individuals’ clothes appropriately. Protective clothing to include gloves and aprons were available. Hand washing facilities were available in all areas where people require to wash their hands. Disinfecting gel was available by the entrance to the units. Several staff are undertaking a distance learning course in infection control. The home has policies, procedures and good practice guidance notices in place. Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing has been reviewed to provide appropriate levels of staffing for the assessed needs of the residents. Training provision is good, thus providing staff with the skills and knowledge to care effectively for the residents. Systems are in place for the vetting and recruitment of staff, thus safeguarding residents. EVIDENCE: The home was being appropriately staffed to meet the needs of the residents. The Deputy Manager is supernumerary and is in charge of the day-to-day clinical overseeing of the home. Both the Manager Designate and the Deputy Manager provide weekend cover so that the home is being managed effectively during the 7 day period. Duty rosters are being done one month in advance and any changes are recorded. The Manager Designate said that she has had a recruitment drive and has employed several permanent and bank staff so that agency staff were no longer being used. This provides better continuity of care being provided by staff who become familiar with the needs and routines of each resident. The home was clean and overall smelled fresh, with the Manager Designate being aware of any isolated issues with odours. The housekeeper said that she has now been provided with staff for domestic and laundry duties in such numbers to effectively meet the needs of the home in these areas. The Manager Designate said that the maintenance person had Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 18 recently left and interviews for a replacement had already been arranged for the near future. Action is also being taken to recruit a permanent cook. 20 of the care staff have NVQ level 2 in care, however the Manager Designate is very aware of the need to increase this number and more staff have been registered to undertake this training. The housekeeper is doing an NVQ in hospitality management. One Inspector viewed staff employment records and with the exception of one photograph these included all the information required under Care Home Regulations 2001. The Manager Designate said that the photograph would be obtained, plus a photo of the person was available on the staff identification board in the foyer. A recent full BUPA audit had been carried out on the staff employment files. BUPA has an induction programme folder that incorporates the Skills for Care common induction standards. There is a training programme in place and there has been an assessment of individual training needs so that future training can be planned and implemented. The home has a training matrix to clearly identify the training undertaken by each member of staff. Staff confirmed that they had received training appropriate to the work they perform. Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. 31, 33, 35, 36 & 38. This judgement has been made using available evidence including a visit to this service. The Manager Designate has the qualifications and experience to manage the home, and is doing so effectively. Good systems for quality assurance are in place, thus providing an ongoing process of management and practice review. Monies held on behalf of residents are being well managed and securely stored, thus safeguarding them. Staff receive regular supervision thus providing a forum for individual discussion and reflection on practice. Systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Manager Designate is a first level nurse with several years of management experience. She also has completed the Registered Managers Award, is a ‘Investors in People’ reviewer, a moving & handling instructor, a fire safety Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 20 trainer and she also has a Teaching & Assessing qualification. Staff spoken with said that the Manager Designate is approachable and supportive and has made a marked positive difference to the overall morale and confidence of the staff team. The Manager Designate operates an ‘open door’ policy and it was clear from discussions with her that she values her staff and wants the best for the residents in her care. The home has an annual operating business plan that identifies the budgets available for each department and the Manager Designate has ensured that each head of department is aware of the budget available to them. A comprehensive audit of the whole home had been carried out in May 2007 and any shortfalls identified had been actioned. Food and activities satisfaction surveys had been carried out and the results acted upon. The response to the BUPA customer feedback questionnaires was poor and therefore an overall result could not be collated. These are to be re-issued to all residents and representatives in August 2007. The Manager Designate was aware of the need to send a copy of the collated results from these surveys to CSCI. Regulation 26 unannounced visits to the home on behalf of the Registered Person take place and copies of the report are forwarded to CSCI. Medication audits are carried out and the dispensing pharmacist also carries out inspections. Heads of department, qualified staff, care staff and unit staff meetings take place and minutes are recorded. Residents and relatives meetings also take place with minutes available. Copies of the BUPA newsletter were available in the front entrance. Plans are in place to contact and engage more with outside organisations, for example, the Alzheimer’s Society. One Inspector sampled the records for monies held on behalf of residents. These were clear and up to date, evidencing all income and expenditure. Receipts for expenditure were available and monies are stored securely. A finance audit by BUPA has been planned. Policies and procedures for the management of monies are in place. The Manager Designate said that staff receive supervision and this is cascaded down. Individual contracts and supervision records are agreed and maintained. The Manager Designate said that she is reviewing the content of the supervision guidance to ensure all areas of practice are included. Servicing and maintenance records were sampled and those viewed were up to date. The fire risk assessment was due for updating and the Manager Designate has since confirmed that this has been addressed. Staff training records evidenced that staff had received training and updates including moving & handling, fire safety, food hygiene, COSHH and health & safety. First aid training is also taking place. The BUPA policy is to carry out fire drills 4 times a year, these being twice during the day and twice at night. This does not ensure all staff working at the home are involved with fire drills at the required intervals and action to address this needs to be taken. This is a repeat finding. Risk assessments were in place for equipment and safe working Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 21 practices and the Manager Designate said that she would ensure that copies of the relevant assessments are available in each department. A health & safety audit had been carried out and action taken to address shortfalls identified. Harefield Nursing Centre DS0000010932.V336412.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Harefield Nursing Centre DS0000010932.V336412.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 OP9 Regulation 13(2) Requirement Timescale for action 20/07/07 2. OP21 23(b) 3. OP38 23(4) The room temperature in the clinic room must not exceed 25°centigrade so that medications are stored at the correct temperature. Action must be taken to address this finding. Timescale of 01/12/06 not met. The grouting in the shower room 01/08/07 needs replacing and the Parker bath provision needs reviewing to provide appropriate, clean and well-maintained assisted bath/shower facilities. Fire drills must be carried out at 20/07/07 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. This is to ensure all staff are trained and competent in the action to take in the event of a fire. An action plan to address this must be put in place. Timescale of 01/12/06 not met Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 24 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 OP38 Good Practice Recommendations 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.V336412.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Harefield Nursing Centre DS0000010932.V336412.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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