Inspection on 02/04/08 for Hartcliffe Nursing Home

This inspection was carried out on 2nd April 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Hartcliffe Nursing Home 29/04/09

Hartcliffe Nursing Home 22/12/08

Hartcliffe Nursing Home 21/02/07

Hartcliffe Nursing Home 27/03/06

Hartcliffe Nursing Home 17/08/05

Hartcliffe Nursing Home 22/02/05

Hartcliffe Nursing Home 13/09/04

Hartcliffe Nursing Home 14/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Hartcliffe Nursing Home Murford Avenue Hartcliffe Bristol BS13 9JS Lead Inspector Jill Cornelius Unannounced Inspection 10:00 2 and 9th April 2008 nd 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 Hartcliffe Nursing Home DS0000031895.V362536.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. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hartcliffe Nursing Home Address Murford Avenue Hartcliffe Bristol BS13 9JS 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) 0117 9641000 0117 9641100 home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Ruth Andrews Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66), Physical disability (10) of places Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 66 persons aged 65 years and over requiring nursing care May also accommodate up to 10 persons with physical disability under the age of 65 requiring nursing care 21st February 2007 Date of last inspection Brief Description of the Service: Hartcliffe Nursing Home is owned by Methodist Homes for the Aged and provides nursing care for up to sixty-six older people and 10 persons with physical disability under the age of 65 requiring nursing care. It is located in a suburban position and can be accessed by public transport. Transport is needed to reach local shops and amenities. The home itself is purpose built and has now been in operation for 5 years. 64 bedrooms are for single occupancy and there is one double room. They are set out over two floors accessible via the passenger lift. Communal space is offered in 4 lounges and there is a spacious dining room on each floor. There is a small garden and parking spaces for visitors. The aims of the home as written in their brochure: • To provide a home from home environment. • To give peace of mind, security, support and stimulation. • To provide a caring environment based on respect and loving support. Additional information about the home is available in a brochure by request. The ranges of fees in the home are from £498 - £672 per week with additional charges being made for hairdressing, chiropody, newspapers, escorts, and toiletries. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection was unannounced, took place over two days and was completed by one inspector. Evidence to form the report has also been gathered from a number of other sources: • Information provided by the manager during the inspection • Talking with some of the registered nurses, care staff and ancillary staff • Observations of staff practices and their interaction with people living in the home • A tour of the home • Case tracking a number of people living in the home • Talking to a number of people living in the home • Talking to a number of visitors • Looking at some of the homes records • Notified incidences in the home, (Regulation 37’s) • Issues in staffing levels reported to us As a result of this inspection there have been three requirements and two recommendations made. What the service does well: The following are some positive comments made in survey forms by relatives and residents; “I believe my relative is very well looked after. I appreciate they can be difficult at times but overall I am happy with the care and attention they get.” “A big thank you for Hartcliffe Nursing Home staff for their unfailing work and care.” “It’s a great relief to the family that our relative is so well cared for. They seem content and have settled very quickly. We also feel the family are well supported.” Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 6 The inspector’s findings were: Prospective residents and their families can be assured that a full assessment will take place before a decision is made about the suitability of the home for each individual. Residents’ benefit from having an activities co-ordinator working at the home. This ensures that there is a varied and ongoing programme of various social events and activities organised for them to participate in if they wish to. The activities organiser also tries to spend time with people who need to be or choose to stay in their room. Spiritual needs are also considered and there are regular events in the home for people to celebrate their religious beliefs. Complaints are taken seriously, investigated fully, and action taken where necessary to amend any areas of weakness. Survey forms confirmed that people feel able to talk to members of staff or the manager about any concerns they have. Staff have regular training in the prevention and detection of abuse. Residents and staff continue to benefit from a manager who is competent and able to meet the homes objectives. There is an open and inclusive management style. Regular meetings are held for various groups throughout the home including residents, relatives and staff groups. The health and welfare of the staff and residents are promoted and protected. There are safety checks done regularly, this includes fire safety tests. Staff also receives regular fire safety training updates. What has improved since the last inspection? Social time spent with those residents who have to or choose to stay in their rooms is now recorded. Key workers are encouraged to spend this social time with the residents in their care. All staff have the opportunity to have regular supervision sessions with their supervisor, whether they work during the day or night. This enables them to discuss their practice and any career developments. There had been some comments on the survey forms received about call bells not being answered promptly and about staff being very busy. The home now has a system in place to monitor the ringing of call bells and how long staff take to respond to those. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 7 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. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 8 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 Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families can be assured that a full assessment will take place before a decision is made about the suitability of the home for each individual. EVIDENCE: The Statement of Purpose has been updated to incorporate the changes in staff. A copy of the document is located in the entrance of the home, and is provided for any prospective new resident. Some of the residents have a “Residents Information “ pack – this is also due to be updated. All newly admitted residents will be provided with a statement of terms and conditions. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 10 The home manager or her deputy under-takes pre – admission assessments for any new residents. The majority of residents come to the home directly following a stay in hospital. One visitor said, “ They had visited a couple of homes and had chosen Hartcliffe to look after their relative”. The home has a comprehensive assessment tool to enable the manager to determine that the home is able to meet the person’s needs. The records of the most recently admitted person were inspected, and provided a clear insight into the residents needs. The assessment along with information obtained from the hospital, evidenced how the home judged it could meet that persons needs. The home offers placement to older people who need assistance with personal care and nursing tasks. It is only able to accommodate people with low to moderate levels of dementia and confusion. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. Residents do not benefit from well constructed care plans as these tend to focus on inabilities and do not consistently record social care needs. Residents are not generally involved with the writing or reviewing of their plans. Residents health care needs are generally regularly assessed and any changes acted upon, although this was not so for one resident suffering pain when having their dressings changed. Residents benefit from medication systems that are safe and well organised. Residents dignity and respect are promoted by staff. EVIDENCE: Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 12 Individual records are kept for each of the residents, which include a social history for some. Five care plans, were inspected and all reflected most of the current identified health needs. Some psychological and social needs were identified on the care plans but actions to meet these needs were not clear, specific or personalised. Two needed minor improvements. These were undertaken during the course of the inspection. In one care plan a risk assessment form showed the resident to have a pressure sore. Use of an assessment tool showed that their pain was high when wound dressings were undertaken, but there was no detail of how the pain should be managed to allow a pain free dressing change. This was discussed with the Registered Nurse on duty. It was agreed that a new plan should be formulated with the assistance of the GP and that this should be done without further delay. This should result in a reduction of the pain experienced by the resident. There were systems in place to monitor progress of wounds to determine that the treatment is effective, by regular photography, wound mapping or measurements being taken. However, basic information about what wound care products were to be used or how often dressings were to be changed were not consistently recorded. For one resident it was difficult to determine when the GP or tissue viability nurse had been contacted for advice. All care plans contained well-formulated risk assessments for Manual Handling, and falls. An audit of falls is done on the computer by the Manager, if a pattern emerges then it is expected that the care plan is to be reviewed. When tracking one resident who had had two falls there was a review of their care plan. Other accident records were checked and staff spoken with about their actions if a resident has a fall. Staff said ‘there is now an overview and this information is used when the care plan is reviewed’. This shows evidence that staff are trying to minimise any risk of falls for those residents who may be at risk. Daily records were up to date and written in a respectful manner. Residents care plans have been reviewed on a monthly basis or sooner if required. There was one care file evidencing that a relative had been involved in this process (resident and /or their representative). It would be good practice if the home undertook re-assessments of their longer-term resident’s needs on at least a yearly basis, to ensure that plans stay up to date and clear. Despite these shortfalls in the homes care planning processes, all residents and relatives who were spoken with during the inspection, were satisfied with the care provided. “I am very happy here, I am well looked after”, “ I would not want to live anywhere else”, and “I receive very good care and support” were examples of comments received. Some residents made comments on the CSCI survey forms that on some occasions call bells can take a while to be Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 13 answered, and one resident stated during the inspection “That it is only certain times of the day”. Residents are registered with a number of different health centres and GP practices. Where possible, residents are encouraged to retain the services of their family GP. Records are maintained of all contacts with GP’s and any other healthcare professionals. Monthly observations to monitor healthcare are undertaken but noted to be sporadic at times. There is a lack of good reliable recordings of bowel function, and this has the potential to place a resident at risk from poor health. This has been referred to again under standard 37. The home has sound procedures in place for ordering, receipt, storage, administration and disposal of medicines. Signage was in place where oxygen cylinders are stored. The home does not store more than one month’s supply of medications. Fridge temperatures for the medicine fridge and the storage room are recorded daily and are within safe range. It was noted on the second day that the morning medication round was still being undertaken at 10.30. This has been referred to again under standard 30. During the course of the inspection, the staff team were seen going about their duties in a friendly courteous manner. Choices and preferences were observed being discussed and offered. They were heard being respectful and in general, using first names to address each resident. One resident said “that they were helped with personal care tasks in privacy, but the staff encouraged them to ‘do for themselves’ where possible”. The person was satisfied with this level of support. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 14 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, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a varied activities programme that caters for most people’s interests. Residents enjoy continued contact with family and friends. Residents benefit from a nutritious and varied diet and are offered choices of meals. EVIDENCE: The home has a full time activities coordinator. The inspector talked with the coordinator and looked at the record of activities and events held in the home. The record for March to the end of April 2008 showed the following; Easter activities, a well attended bingo session, craft classes, books and magazines, Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 15 songs of praise, sing-along with Dave, Alan’s music group, a singer, holy communion and the taking round of the shop. Forthcoming events include a quiz night. The records of events held were detailed and included which residents had joined in, and whether or not they had enjoyed the event. The co-ordinator also tries to spend time with those residents who choose to or have to be in their bedrooms. For residents who do not join in those activities staff should spend time with them, which is not about delivering care. The coordinator puts information in the care plans and has been adding some life history details, which she has found out both from the residents themselves and from relatives. There is also an annual planner showing various events, which are to be carried out throughout the year, this included celebration of religious events such as Easter. The co-ordinator would also like to be involved in encouraging the keys workers in spending more one to one time with residents and assisting with some of the activity events held. Two residents’ spoke very positively about the activities coordinator and said how cheerful and helpful she is. The home has a spacious dining room, which was well used on both days of the inspection. The tables were laid with attention to detail. Staff assisted those residents who needed help with their meal discreetly. It was noted that some residents who perhaps have a smaller appetite, had smaller plates and appropriate portions. Menus are seasonal and discussed at residents meetings. The menus are displayed in reception. The catering manager meets new residents and has a list of likes / dislikes in the kitchen. The residents are asked every day what they would like for their meals. The kitchen staff are informed of individual problems such as weight loss, and take steps therefore to increase their calorie intake. Cultural needs are also taken into account. It was noted throughout the home that fresh fruit was on display. Homemade cakes are made daily and also home made biscuits. The kitchen had an Environmental Health inspection in 2006 in which no recommendations or requirements were made. This means that the home does not have to have another inspection for 2 years. This is commended. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 16 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. Residents can be assured that any complaints they may have will be listened to and acted upon and that they will be safeguarded from harm. EVIDENCE: The homes Complaints Procedure is included in their Statement of Purpose and Service Users Guide and is also displayed in the main reception area of the home. All residents and relatives who were spoken with during the visit to the home stated that they were aware of how to make a complaint and felt happy about raising any concerns. The manager explained that it is the homes ethos to develop good relationships with each resident and their families right from the day they are admitted to the home. This encourages the opportunity for concerns to be raised before they become serious issues. One survey response to the CSCI ‘felt that their concerns were not responded to appropriately’. The manager was informed of this and hoped that this would not happen again. One relative commented, “if something is wrong then I tell someone and it is sorted out”. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 17 The home has a Protection of Vulnerable Adults (POVA) policy. Those staff spoken with during the course of the inspection showed good basic awareness of adult protection issues and of their responsibilities in safeguarding the residents from harm. Staff referred to the homes whistle blowing policy and would not hesitate in reporting any bad practice. Staff receive POVA training as part of their induction-training programme and also on a refresher basis. This will ensure that safeguarding issues remain paramount. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 18 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, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy homely and comfortable surroundings. Outdoor space is attractive and accessible for residents to enjoy. The home has suitable equipment to maximise residents’ independence. Robust Infection control practices are followed. EVIDENCE: Hartcliffe Nursing Home is purpose built and set out over 2 floors. The corridors are wide allowing for easy wheelchair access. It is well maintained. Residents are encouraged to personalise their room and bring in small items of furniture. The furniture, fixtures and fittings are appropriate to the client group and age group. Some of the communal rooms have new curtains and Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 19 wall prints. Residents spoken with said, “They had chosen the prints”. The manager said that there are plans for redecoration and renewal of some furniture this coming year. There is a spacious lounge, which has level access to the patio and garden. There are ample assisted toilets and bathing facilities. It was noted that the 2 main bathrooms on both floors have been tastefully decorated with a lot of thoughtful touches. One bathroom on the ground floor is to be converted to a shower room. Plans are underway for this. Windows on the far side of the building have been shuttered up due to construction work being undertaken. This omits the light and fresh air for residents in rooms numbered 11,12, 13, 14, 15, and 16. No evidence of risk assessments relating to this has been undertaken. No contact relating to this event was forwarded to the commission through a regulation 37 notification. This was requested during the inspection. One of the residents in this room said, “I don’t mind they need to do the work, I am out of my room a lot of the day”. There are 64 single bedrooms and one double room. All bedrooms meet the national minimum standard size. It was noted that there were colourful nameplates on each bedroom door. These were individualized. All of the beds in the home are electrically adjustable which makes for safe manual handling for both staff and residents. There is lockable storage in each room. It was seen that all bedroom doors are held open with automatic closures on them so that doors will be kept open for residents’ preferences, but comply with fire regulations. This is commended. It was noted that the home has several lifting hoists and stand aids for manual handling purposes. It was noted that the home was clean. However, there was a musty smell on entering the reception area. The manager was informed of this. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a mix of staff that are sufficient to meet their needs. Residents are protected by a robust employment system that safeguards and protects them. Residents can be confident that staff training will benefit their work in meeting their needs. EVIDENCE: The home has a full compliment of care staff and qualified staff, supported by a bank of staff, which can be called upon to cover any shifts required. The home do not use agency staff at all - this therefore means that the residents will be looked after by staff who are familiar with their needs. Several comments were made on the day of the visit by residents’ regarding the need for more staff, however the home does staff the home above the agreed staffing notice. Those staff spoken with during the course of the inspection did agree that at certain times of the day and night, it could be extremely busy. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 21 Discussion with the manager and the deputy manager evidenced that they are looking at how they can use staff hours to cover these busier times. The manager pointed out that there had been a change in the medication round start time from 8am to 9am so that the Rn’s where available. The manager said a survey of the residents’ will be undertaken and this will hopefully show an improvement. A team of administration staff, housekeeping, laundry, maintenance and catering staff are also employed and provide support in meeting the residents daily living needs. The home currently has some staff who have already obtained an NVQ Level 2 or 3 in care and a number of staff who are working towards the award. Housekeeping staff is also encouraged to undertake NVQ training. All new recruits to the care team are expected to undertake NVQ training after they have completed their induction training and probationary training. A training log is kept for each staff member and evidences that they have attended a range of relevant training outside of the Home, as well as that provided by the home. Staff have to attend all mandatory training courses, such as fire awareness, manual handling, protection training, and health & safety as an example. The manager has put together a training matrix to identify clearly the staff that are due for refresher training. The home also has an on-going programme for NVQ and all staff have either completed or are working towards their NVQ award. The previous inspection identified that supervision sessions were not being conducted in the way that is expected to meet the standards. This is now being undertaken both in the frequency of the sessions and the content of the sessions. The content was now covering all aspects of practice, philosophy of care in the home, and career development needs. In order to determine that the home follows safe recruitment procedures, the files of all staff that have started working at the home this year were examined. For each person there was a written application, two written professional references with at least one from a previous employer, a declaration of medical fitness and CRB checks. There are procedures to monitor that the qualified nurses have maintained their NMC (Nursing and Midwifery Council) registration and that work permits remain up to date. All the files were in order evidencing that the homes follow safe procedures and ensure that only suitable staff is employed. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from an experienced, competent and caring Manager. Residents can be confident that their views will be sought to ensure that the home meets its aims and objectives. Residents benefit for being cared for by staff that are appropriately supervised. Residents and staff can be confident that their safety and welfare are promoted. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 23 EVIDENCE: Mrs Andrews continues to be the registered manager of the home. She is a registered nurse and very experienced in the care of the elderly. She works full time in addition to the staff on the floor, and has recently recruited a new deputy manager. The manager is very professional, approachable and friendly. Staff spoken with and residents and relatives spoken with during the inspection verified this. The commission received 24 completed survey forms to inform the inspection, from residents and relatives. The home also had a standards and value assessment completed by the Methodist Homes group in September 2007. The outcome from this identified some actions needed to take place in relation to one to one activities, gaps in recording and filing of care plans, staff files and training records. These areas have been written about within this report. The manager undertakes supervision sessions. These are being conducted to meet the standards. This was both in the frequency of the sessions and the content of the sessions. The supervision records for 4 members of staff were viewed and evidenced this. Staff spoken with also confirmed that they receive supervision. The home employs a full time maintenance person who is responsible for some of the health and safety checks. They work full time and are on call. Apart from the fire safety tests the maintenance person also checks the safety of the portable appliances, the wheelchairs, the safety of bedrails, that the window locks are secure and the call bell system. They also update a joint risk assessment of the building with the manager. The fire log record shows that there are weekly checks of the alarm system, visual checks of the extinguishers and visual checks of the emergency lights and sensors. Records show regular unannounced fire drills incorporating evenings, weekends and nights. There are monthly checks of the water temperatures to ensure that the restrictive valves keep the temperature of the hot water below 45 degrees centigrade. The checks to test for legionella are also completed regularly. We asked the maintenance person about the safety checks for bedrails, the bedrails are all integral to the beds so the safety checks are to check the gap between the bedrail and the bottom of the bed is below the minimum distance recommended. Records are also held of maintenance checks by contractors such as ARJO for the hoists, stand aids, bath chairs and the sluice. An external contractor also maintains the lift. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 24 Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x 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 x 3 x 3 Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) (2) Requirement The registered person shall ensure that care plans cover all aspects of the service user’s health, personal and social care needs. Timescale for action 30/08/08 2 OP7 15 3 OP25 23(2)(p) There also needs to be evidence that the plans are written with the service user and/or their representative and reviewed with them. The registered person shall 18/05/08 ensure that the wound care plan and pain risk assessment with actions (identified during the inspection as being inadequate) is re-written. 18/05/08 The registered person shall ensure that the rooms numbered 13 – 16 are provided with natural day light as soon as practical. There also needs to be evidence that those people are kept informed of progress and offered alternative rooms when they are available. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 27 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 OP27 OP12 Good Practice Recommendations The registered person shall continue to monitor the busy times and action appropriate numbers of staff. This will ensure residents have access to assistance they require. Staff should spend time with residents who do not participate in activities. Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Hartcliffe Nursing Home DS0000031895.V362536.R01.S.doc Version 5.2 Page 29 - 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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