Inspection on 18/07/05 for Hayes Court

This inspection was carried out on 18th July 2005.

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

Hayes Court 08/04/08

Hayes Court 29/05/07

Hayes Court 29/06/06

Hayes Court 22/02/06

Hayes Court 14/01/05

Hayes Court 19/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hayes Court Nursing Home 50 Hayes Lane Kenley Surrey CR8 5LA Lead Inspector Mohammad Peerbux Unannounced Inspection 18 July 2005 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 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. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hayes Court Nursing Home Address 50 Hayes Lane, Kenley, Surrey, CR8 5LA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8660 3432 020 8668 4522 Dr Michael Sturgess Care Home 56 Category(ies) of Old Age (56) registration, with number of places Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom accommodation is provided at any one time whall not exceed 56 (fifty six). 2. Elderly Infirm (including 5 convalescent). 3. A variation has been granted to allow one specified resident under the age of 65 to be admitted. Date of last inspection 14 January 2005 Brief Description of the Service: Hayes Court is a 56-bedded care home. It provides both nursing and residential care. The home is set in its own quite substantial grounds about a mile from Kenley railway station. Access for wheelchair users is available. There are three floors with access by stairs or a small passenger lift. The home provides the possibility a double room on each floor, though only one can be occupied doubly at any one time to keep within the registered number. The remaining bedrooms are all single occupancy; all bedrooms have en-suite facilities. The majority of rooms are located on the ground floor, with a small number in the original main building on first and second floors. There are a number of communal areas located throughout the home, and a conservatory for the use of service users. Parts of the garden are also accessible to them. Visitors may be seen in private in users’ rooms, or in one of the small lounges. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2005/06. It was an unannounced inspection and took place over four hours. Some times were spent looking at the policies and procedures, talking to the proprietor, matron and to some of service users. They are all thanked for their time and assistance. A tour of the building was also carried out and some service users were met in their rooms. Service users spoken to stated that they were happy with the care being provided. While this was the home’s first inspection in this current (inspection) year, it should be noted that additional visits, on top of the two statutory inspections, were made to the home during this year, because the Commission received an anonymous complaint and there were also concerns around medications. The registered provider has been asked to meet a number of requirements over the course of those visits. Comment will be made on these overleaf. What the service does well: What has improved since the last inspection? The home had a health and safety visit by an external company on the 24th of June 2005.A copy of the report is available on request. The registered provider has appointed a person on a supervisory role to overlook the quality assurance and entertainments for service users in the home. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 6 The home has produced a newsletter for the month of July giving a lot of information about the home and its future activities. What they could do better: The Statement of Purpose must be amended with regards to the organisational structure of the home and the number, relevant qualifications and experience of the staff working at the home and the Service Users Guide must include a copy of the latest inspection report. The service user’s plan must be reviewed and updated on a regular basis to reflect changing needs and current objectives for health and personal care. Staff must receive training in the support service users with visual (and hearing) impairments. The registered person must ensure that all the medication not supplied in the monitored dosage system is counted and recorded and the use of medication monitored after one week. The administration/non-administration of all medication must be recorded accurately and all medication must be given as the prescriber directed.There must be a safe and secure system of medication administration in accordance with professional guidelines and clear directions for administration must be in place for all items of medication. The allergy section on the medication profiles must be completed for all service users and the receipt of all medication into the home must be recorded accurately. All medication no longer prescribed for service users must be removed from use and disposed of appropriately. All staff including ancillary staff must receive training in Adult Protection. The Registered Provider must ensure that staff records contain all the details listed in schedule 2 of The Care Homes Regulations 2001. All staff must have an individual training and development assessment and profile in place in order for them to fulfil the aims of the home and meet the changing needs of service users. The registered provider must ensure that quality assurance surveys are extended from service users, relatives and friends to include visiting professionals, voluntary workers and any other stakeholders. The home’s providers need to evidence (in a Development Plan) that the home is meeting its aims and objectives and is being run in the best interests of service users. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 7 The registered provider must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. The home must have a policies and procedures checklist. This should list all of the home’s policies and procedures, indicating when each policy was last reviewed. A copy should be included in each staff file, and should evidence that staff have read and understood each policy developed and reviewed. The fire door in the dining room is not closing properly and must be adjusted and the cupboard under the stairs by room 38 must be kept locked. 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. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 and 5 Changes are needed to the Statement of Purpose so that it accurately reflects full information about the services on offer. This will provide the correct information to enable people to make informed decision about the home on whether it will meet their needs. Opportunities to visit the home is being made available to service users, enabling an informed choice regarding the suitability of the home to be made. The home is able to demonstrate that service users needs are being properly assessed. EVIDENCE: The Statement of Purpose must be reviewed with regards to the organisational structure of the home and the number, relevant qualifications and experience of the staff working at the home. Since the last inspection the registered manager has left and is working for another provider. The registered provider must ensure that the Statement of Purpose is updated again when a new manager is appointed and registered. The Service Users Guide is Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 10 comprehensive however it needs to include a copy of the latest inspection report. Three service users’ contracts were sampled. They outlined exactly what services are provided. They were all dated and signed by the home and the service users or representatives. Two service users have been admitted to the home recently. It was noted that both of them had a full assessment undertaken. The registered provider stated that prospective service users are invited to visit the home and to meet service users and staff. The service user and his/her relatives are fully involved in the process leading up to an admission, and given the opportunity to fully assess the suitability of the home. Service users are normally offered a month’s trial at the home, with immediate notice on either side being understood. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 11 Service users’ personal, physical and emotional health needs are not being reviewed on a regular basis. This does not ensure that the service users’ physical and emotional health is being maintained and therefore the quality of life experienced is not being maximised. The home has arrangements for the ordering, storage, recording and disposal of medication and has access to a pharmacist for advice. Omissions and errors in recording, errors and poor practice in medication administration were found that put service users health and welfare at risk. EVIDENCE: A number of service user plans were inspected. Some of them have not been reviewed. However the care plans that were sampled during the investigation of a complain made in June 2005, were all reviewed. The registered provider must ensure that service user’s plan are reviewed and updated on a regular basis to reflect changing needs and current objectives for health and personal care. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 12 The matron was able to demonstrate, through individualised healthcare records, that service users are in regular contact with General Practitioners. The home also keeps records of all the service users healthcare appointments, in addition to individual daily progress notes. The registered provider stated no service users have pressure sores at present. It was previously required that staff must receive training in the support service users with visual (and hearing) impairments. This has yet to be achieved and therefore this requirement will be repeated. The Pharmacy inspector carried out an inspection on the 14/07/05 following concerns regarding medications. A number of requirements and recommendations were made and they were as follows: No Regulation Required Action Timescale for action 1 2 3 4 5 Regulation 13 (2), Care Standards Regulation 2001 Regulation 13 (2), Care Standards Regulation 2001 Regulation 13 (2), Care Standards Regulation 2001 Regulation 13 (2), Care Standards Regulation 2001 Regulation 13 (2), Care Standards Regulation 2001 The registered person must ensure that all the medication not supplied in the monitored dosage system is counted and recorded and the use of medication monitored after one week The registered person must ensure that the administration/non-administration of all medication is recorded accurately. 10pm 14th July 2005. 15th July 2005. The registered person must ensure that all medication is given as the prescriber directed. 15th July 2005. The registered person must ensure that a safe and secure system of medication administration is in place in accordance with professional guidelines. The registered person must ensure that clear directions for administration are in place for all items of medication. 25th July 2005 1st August 2005 Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 13 6 7 8 Regulation 13 (2), Care Standards Regulation 2001 Regulation 13 (2), Care Standards Regulation 2001 Regulation 13 (2), Care Standards Regulation 2001 The registered person must ensure that the allergy section on the medication profiles is complete for all service users. 1st August 2005 The registered person must ensure that the receipt of all medication into the home is recorded accurately. 1st August 2005 The registered person must ensure that all medication no longer prescribed for service users is removed from use and disposed of appropriately. 1st August 2005. No 1 2 Standards 9 9 RECOMMENDATIONS Good Practice Recommendations It is recommended that temperature in the medication storage cupboard is recorded and monitored. The temperature should be maintained below 25oC. It is recommended that the dosage directions on the administration record be written fully in words rather than in codes and figures. It was previously required that staff must receive training and supervision to ensure their conduct remains professional and caring at all times so as not to compromise the dignity of service users. The registered provider assured me that this has now been achieved. The home has a comprehensive list of policies and procedures dealing with matters relating to the dying and the death. The registered provider stated that the wishes regarding arrangements after death are discussed and recorded in individual care plans. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 15 Service users are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. However more could be done to encourage their participation in day-today activities. They are assisted to maintain contact with family and friends, and links with the local community. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Service users are evidenced as being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and spiritual needs. However more could be done to encourage their participation in day-to-day activities. There is also a list of activities that is mentioned in the home’s newsletter. The matron advised that an activities co-ordinator will be starting soon and then the service users will have a wider choice of activities. However it is recommended that the home have a weekly activities timetable in place and which the service users can have access to. Service users are encouraged to maintain contact with friends and relatives and to develop links with the local community. The registered provider stated Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 15 that visitors are welcome at the home at any time however they have to phone if they are coming after 8pm as the doors are locked after that time. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. The menus offer a choice of meals, and when the published menu options are not desired on the day, alternatives are offered. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 and 18 Service users, their relatives and friends can be confident that their complaints will be taken seriously and acted upon as an appropriate complaints policy and procedure is in place. Service users’ legal rights are protected. The home has an appropriate adult protection policies and procedures in place. However all staff including ancillary staff must receive training in Adult Protection to ensure service users are protected from abuse and are living in a safe environment. EVIDENCE: Adequate procedures are in place for dealing with complaints. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. There has been an anonymous complain made directly to the Commission last month. There were six elements to the complaint and they were all investigated .The outcome was as follows: There were 48 service users at the times of this inspection. The staffing level was discussed with the Registered Provider in the absence of the Registered Manager. He agreed that there is a shortage of carers in the home at present. The Registered Manager is currently in the process of recruiting more staff. She was on leave at the time of this inspection. In the meantime the current staff are doing extra hours to cover the shortfall. On duty at night carers do domestic work as well as caring work during the night. Service users are divided into 4 patches. Each carer has approximately 14 service users to look after. The domestic work includes vacuuming the communal area, general tidy up of the home and doing the laundry mainly washing the sheets and blankets. She also stated “the carers are kept busy Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 17 during the night”. However if there is any emergency then the domestic works are carried forward to the day shifts. The inspector could not find any evidence to say that carers should carry out domestic work at night. It is recommended that this be mentioned in the staff job descriptions. Further visits will be carried out to ascertain the balance of work between domestic and care. The Registered Provider and the registered nurse in charge stated that some service users have had scabies in the past around Christmas time. They were all treated. The inspector informed the registered provider that he is going to contact the service users’ General Practitioner to confirm the treatment. At the times of this inspection no one had scabies. The Registered Provider advised that they are supplied with incontinent pads as part of free nursing care from the Primary Care Trust .He also stated that staff have access to the pads when and as needed. The inspector was able to see that home had a good supply of pads. A sample of service user files was examined. The home was evidenced to have appropriate assessments and care plans in place. Service users’ care and support needs had been properly assessed, and the range of health, care and social needs presented were evidenced as being met. The care plans are regularly reviewed. However, the level of care being provided could be compromised due to the shortage of staff in the home. Staff records were examined and were seen to contain references, criminal record checks, original application forms and copies of identification. One of the staff files sampled did not have any identification .The manager must ensure that staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001.This element is partly upheld. In order to protect the service users receiving the service provided by Hayes Court Nursing Home the following requirement and recommendation were made. The registered provider advised that all service users are registered on the electoral roll and would be supported to vote if they wished to. The home has a copy of London Borough of Croydon adult protection procedures. However all staff including ancillary staff must receive training in Adult Protection. There have not been any adult protection concerns raised since the last inspection. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21,25 and 26 Generally the home is safe, clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional well- being. EVIDENCE: The home is situated in substantial grounds, some parts of which are accessible to users. The surrounding terrain is hilly - and therefore difficult for people with limited mobility. The home provides a satisfactory amount of communal space. There is also a very pleasant, well-furnished, conservatory. Two issues were noted during this inspection with regards to environment. The fire door in the dining room is not closing properly and the cupboard under the stairs by room 38 was left unlocked. There is a sign on the cupboard door saying ‘Keep Locked Shut’ .The registered provider must ensure that the fire door is adjusted so that it closes properly and the cupboard under the stairs is kept locked (see standard 38). Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 19 There are sufficient numbers of toilet and bathroom facilities near service users bedrooms and communal areas on each floor of the home. Toilets inspected were all noted to be clean and well maintained. The home is appropriately heated, lit and ventilated. A sample of bedrooms were checked and found to be acceptable. They were clean and tidy. It was previously required that the home must be kept clean and free of offensive odours. In general the home was clean, tidy and free of unpleasant odours during this inspection. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 The home has the numbers and skill mix of staff sufficient to meet service users’ needs and ensure their safety. However the home needs to implement a staff training and development programme. EVIDENCE: Copies of the off duty rotas were seen. The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs. The registered provider informed that 8 staff have NVQ Level 2 and 3 staff have NVQ Level3. The management team are aware that they will have to give consideration as to how this standard will be achieved. There is an appropriate procedure for the recruitment of staff. It was previously required during the investigation of the anonymous complaint that the Registered Provider must ensure that staff records contain all the details listed in schedule 2 of The Care Homes Regulations 2001. The timescale for action was 31/07/05. Some staff records were examined and were seen to contain references, criminal record checks, photos, original application forms and copies of identification. However it is recommended that the home keep a Polaroid photograph of each staff in their files, as some of the photographs are difficult to see. New staff members receive a structured induction. However the home does not have a staff training and development programme in place. The registered Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 21 provider must ensure all staff have an individual training and development assessment and profile in place in order for them to fulfil the aims of the home and meet the changing needs of service users. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34,36,37 and 38 The home needs to further develop its quality assurance processes so as to include the views of visiting professionals and other stakeholders. The home’s providers need to evidence (in a Development Plan) that the home is meeting its aims and objectives and is being run in the best interests of service users. One-to-one supervision sessions are still not being held with staff on a regular basis, this could affect the staff’s ability to consistently meet the service users’ needs. EVIDENCE: Since the last inspection the registered manager has left and is working for another provider. The registered provider stated that he is actively recruiting for a new manager however if he has not found the right candidate by September 2005 then he will put his application in to become the registered manager. The matron is in charge at present in the absence of the registered provider. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 23 Quality assurance tools currently include service user meetings, user/relatives satisfaction surveys, auditing and a complaints system. However the home must further develop its quality assurance processes so as to include the views of visiting professionals and other stakeholders. The home’s provider needs to evidence (in a Development Plan) that the home is meeting its aims and objectives and is being run in the best interests of service users. This was a requirement from the previous inspection and will be repeated. An up to date Public Liability Insurance Certificate was seen in the home and a statement was available from the Proprietor confirming the establishment’s continuing financial viability. From staff supervision records it seems that not all staff are having at least six sessions per year. The registered provider must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. It is also recommended that staff have an annual appraisal in order to review staff performances against their job descriptions and agree career development plans. The home’s policies and procedures were not well organised. A requirement for the registered provider to develop a policies and procedures checklist is made. This should list all of the home’s policies and procedures, indicating when each policy and procedure was last reviewed. A copy of the checklist should be included in each staff file, to evidence that staff have read and understood each policy developed and reviewed. Two health and safety issues arose during this inspection. The fire door in the dining room was not closing properly and the cupboard under the stairs by room 38 was left unlocked. Requirements have been made for these matters. It was previously required that the home must provide evidence to the Commission, that any suspected asbestos products within the home have been professionally identified, then labelled, sealed and left, or safely removed as risk assessment indicates, and under Health and Safety regulations. See also Regulation 4 of the Control of Asbestos at Work Regulations 2002.This was carried out during a health and safety visit at the home on the 24/06/05. A copy of the report was available on request. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 24 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 3 x 2 3 x 2 2 2 Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 25 yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4(1)( c ) Requirement The Statement of Purpose needs reviewing with regards to the organisational structure of the home and the number, relevant qualifications and experience of the staff working at the home. The Service Users Guide must include a copy of the latest inspection report. The registered provider must ensure that service user’s plan are reviewed and updated on a regular basis to reflect changing needs and current objectives for health and personal care. staff must receive training in the support service users with visual (and hearing) impairments.Prevoius timescale of 30/10/04 not met. The registered person must ensure that all the medication not supplied in the monitored dosage system is counted and recorded and the use of medication monitored after one week The registered person must ensure that the administration/nonadministration of all medication Timescale for action 30/09/05 2. 3. 1 7 5(1)(d) 15(2)(b) 30/09/05 30/09/05 4. 8 13(1)(b) 30/09/05 5. 9 13 (2) 10pm 14th July 2005. 6. 9 13 (2) 15th July 2005. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 26 is recorded accurately. 7. 8. 9 9 13 (2) 13 (2) The registered person must ensure that all medication is given as the prescriber directed. The registered person must ensure that a safe and secure system of medication administration is in place in accordance with professional guidelines. The registered person must ensure that clear directions for administration are in place for all items of medication. The registered person must ensure that the allergy section on the medication profiles is complete for all service users. The registered person must ensure that the receipt of all medication into the home is recorded accurately. The registered person must ensure that all medication no longer prescribed for service users is removed from use and disposed of appropriately. All staff including ancillary staff must receive training in Adult Protection. The Registered Provider must ensure that staff records contain all the details listed in schedule 2 of The Care Homes Regulations 2001. The registered provider must ensure all staff have an individual training and development assessment and profile in place in order for them to fulfil the aims of the home and meet the changing needs of service users. The registered provider must ensure that quality assurance surveys are extended from service users, relatives and 15th July 2005. 25th July 2005 9. 9 13 (2) 1st August 2005 1st August 2005 1st August 2005 1st August 2005. 10. 9 13 (2) 11. 9 13 (2) 12. 9 13 (2) 13. 14. 18 29 18(1)(c) 13(6) 19 31/12/05 30/09/05 15. 30 18(1)(c) 30/09/05 16. 33 24(1)(a) & (b) 30/09/05 Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 27 17. 33 24(2) 18. 36 18(2) 19. 37 12(1)(a), 18(1)(a) 20. 21. 38 38 13(4) 13(4) friends to include visiting professionals, voluntary workers and any other stakeholders. The home’s providers need to evidence (in a Development Plan) that the home is meeting its aims and objectives and is being run in the best interests of service users.Previous timescale of 1/4/2005 not met. The registered provider must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. Previous timescale of 1/4/2005 not met. The home must have a policies and procedures checklist. This should list all of the home’s policies and procedures, indicating when each policy was last reviewed. A copy should be included in each staff file, and should evidence that staff have read and understood each policy developed and reviewed. The fire door in the dining room is not closing properly and needs adjusting. The registered provider must ensure that the cupboard under the stairs by room 38 is kept locked 30/09/05 30/09/05 30/09/05 18/07/05 and henceforth 18/07/05 and henceforth 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 9 Good Practice Recommendations It is recommended that temperature in the medication storage cupboard is recorded and monitored. The G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 28 Hayes Court Nursing Home 2. 3. 4. 5. 6. 9 12 27 29 36 temperature should be maintained below 25oC. It is recommended that the dosage directions on the administration record be written fully in words rather than in codes and figures. It is recommended that the home have a weekly activities timetable in place and which the service users can have access to. It will also be good practice for the domestic duties to be mentioned in the staff job descriptions. It is recommended that the home keep a Polaroid photograph of each staff in their files, as some of the photographs are difficult to see. It is also recommended that staff have an annual appraisal in order to review staff performances against their job descriptions and agree career development plans. Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 29 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Hayes Court Nursing Home G53 S19027 HayesCourt V200866 180705 stage4.doc Version 1.40 Page 30 - 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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