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Inspection on 26/06/07 for Hebburn Court Nursing Home

Also see our care home review for Hebburn Court Nursing Home for more information

This inspection was carried out on 26th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff involves the residents, their representatives and other professionals in the care planning to makes sure their needs can be met. The staff have formed good relationships with the residents and make sure their rights to privacy and dignity are met. There is good communication with other professionals to ensure peoples health care needs are met. Visitors are made welcome and there are good links with the local community.Residents and relatives said they would be able to use the complaints procedure if they had a concern. The activities organiser works hard to provide activities inside and outside of the home. The meals are nutritious, nicely presented and choices are available. Residents said: "The food is good" "I get plenty to eat " The recruitment policies are followed. Staff training continues so that all staff can give a person centred approach to care delivery. The quality of the home is regularly tested to make sure that it continues to improve. Comments from the surveys that were returned to the Commission included: "The home provides a high standard of accommodation" "It is very good and the staff are very helpful" "Very nice the short time I have been here" "I received a welcome pack" "Well looked after" "All needs are met" "The care staff are committed and carry out their duties with sensitivity" "Concerns are immediately rectified" "The manager is always willing to listen and act upon suggestions" "The food is plentiful and varied, wholesome and nourishing" "There are arrangements for outings, meals and visits to the theatre"

What has improved since the last inspection?

Clear information is provided about the home so that residents know what to expect before they go to live there. The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. The care plans have been improved and now give detailed information about all aspects of individuals needs. Some areas of the home have been redecorated and some bedrooms have new carpets.

What the care home could do better:

Improvements to the environment must continue to take place. Replacement of carpets and chairs must take place to make sure the home remains a pleasant place to live. Bathrooms and toilets need to be redecorated and some flooring replaced Improvements to the cleaning of the home must continue to make sure there are no odours and bathroom areas are always clean. Staffing deployment on the upstairs unit should be looked at so that all residents can enjoy their meal with the personal support and assistance of staff. Comments from the surveys that were returned to the Commission included: "There are always some clothing that goes missing, more care is needed" "Sometimes all residents are treated the same" "Some staff have better skills than others" "Need more communication with relatives" "Notices about activities are not up to date" "Residents sometimes have to wait to be taken to the toilet"

CARE HOMES FOR OLDER PEOPLE Hebburn Court Nursing Home The Old Vicarage Witty Avenue Hebburn Tyne And Wear NE31 2SE Lead Inspector Irene Bowater Unannounced Inspection 26th June 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hebburn Court Nursing Home DS0000039411.V336571.R02.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. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hebburn Court Nursing Home Address The Old Vicarage Witty Avenue Hebburn Tyne And Wear NE31 2SE 0191 428 1577 0191 483 5555 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) www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited Mrs Carole Ann Craig-Gilby Care Home 55 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (28), of places Physical disability (15) Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may admit up to 5 service users in the dementia (DE) category. 22nd September 2006 Date of last inspection Brief Description of the Service: Hebburn Court Nursing Home is a purpose built home situated in a quiet and discreet residential area of Hebburn, at the site of an old vicarage. The rear of the building provides a pleasant garden view and ample privacy. The Home is registered to accommodate up to 68 older people who require personal and/or nursing care, including up to 15 people with physical disabilities. Recently the home has been registered to care for up to 18 people who have Dementia needs and who also require nursing care. A separate unit, named The Rivers, has been developed on the first floor of the home accessible by a passenger lift as well as stairs. The unit is divided in two parts, Tyne View and Wear View. In total throughout the home there are 44 single bedrooms, and 12 double bedrooms that are used for single occupancy. En-suite facilities are not provided but there are adequate toilets and bathroom facilities throughout the building. A large central reception area on the ground floor provides seating, in addition to the large lounge/dining areas, and is available to service users and visitors. A separate smoking lounge is provided. A large patio with seating facilities is provided to the rear of the ground floor lounge. Access for wheelchair users is available throughout the Home. The Home is within easy reach of public transport facilities, and the local shops and amenities. The Home is about one mile from Hebburn town centre and approximately two miles from the nearby town of Jarrow. Fees for this service range between £355 and £482 per person per week. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 22 September and 11 October 2006. • How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff and other professionals The Visit: An unannounced visit was made on date 26 June 2007 During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors • Looked at information about the people who use the service and how well their needs are met • Looked at other records which must be kept • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last visit • We told the manager what we found. What the service does well: Staff involves the residents, their representatives and other professionals in the care planning to makes sure their needs can be met. The staff have formed good relationships with the residents and make sure their rights to privacy and dignity are met. There is good communication with other professionals to ensure peoples health care needs are met. Visitors are made welcome and there are good links with the local community. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 6 Residents and relatives said they would be able to use the complaints procedure if they had a concern. The activities organiser works hard to provide activities inside and outside of the home. The meals are nutritious, nicely presented and choices are available. Residents said: “The food is good” “I get plenty to eat “ The recruitment policies are followed. Staff training continues so that all staff can give a person centred approach to care delivery. The quality of the home is regularly tested to make sure that it continues to improve. Comments from the surveys that were returned to the Commission included: “The home provides a high standard of accommodation” “It is very good and the staff are very helpful” “Very nice the short time I have been here” “I received a welcome pack” “Well looked after” “All needs are met” “The care staff are committed and carry out their duties with sensitivity” “Concerns are immediately rectified” “The manager is always willing to listen and act upon suggestions” “The food is plentiful and varied, wholesome and nourishing” “There are arrangements for outings, meals and visits to the theatre” What has improved since the last inspection? Clear information is provided about the home so that residents know what to expect before they go to live there. The staff collect information together about the person before anyone moves into the home to make sure they can meet their needs. The care plans have been improved and now give detailed information about all aspects of individuals needs. Some areas of the home have been redecorated and some bedrooms have new carpets. Hebburn Court Nursing Home DS0000039411.V336571.R02.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. Hebburn Court Nursing Home DS0000039411.V336571.R02.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 Hebburn Court Nursing Home DS0000039411.V336571.R02.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): 1,2,3. (Standard 6 does not apply to this home.) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information about the service before being admitted. This means that they can be sure the home can meet their individual needs. The admission assessments ensure the residents care needs will be met. EVIDENCE: The service user guide makes sure people who use the service have all the information they need to make choices about the home. A copy of the guide is available and given to each resident on admission. The guide includes information about how peoples’ rights will be respected regardless of age, gender, sexual orientation, race and religion. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 10 All people who use the services have an agreed contract. They give information about any charges in the home. Care plans show that the manager carries out comprehensive assessments before any resident is admitted. The care managers’ and nurse assessments were also available. Information is also available about residents’ previous lifestyles, including background, cultural, religious or other needs and how this will help residents to settle into the home. The assessment looks at what each person can do to take of themselves and what support they will need with the tasks of daily living and personal and health care. Where possible the relatives and representatives are involved in this process. Hebburn Court Nursing Home DS0000039411.V336571.R02.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 good. This judgement has been made using available evidence including a visit to this service. The care planning systems provide staff; residents and their representatives with the information they need to make sure residents individual needs are met. Health and personal care is well met so that the care people receive is based on their individual needs. Robust systems for the administration of medicines are in place. Further improvements will make sure that residents receive their medication safely. A good level of personal support is in place, which promotes peoples rights to privacy and dignity. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 12 EVIDENCE: All of the plans were clearly set out and up to date. Accredited assessments tools for the prevention of pressure sore and wound care, moving and assisting, catheter care, continence promotion, nutrition and mental health status were completed and reviewed and updated monthly. All of the care plans are regularly reviewed and updated according to changes in social, personal and health care needs. Residents who have reduced appetite or low weights are regularly weighed and intervention sought from dieticians. Their recommendations are acted upon and the care plans updated as necessary. Up to date information regarding changes in wound care is documented on a regular basis and regular reviews take place with residents’, their relatives and care managers to make sure the home is still meeting their needs. The residents have access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. There are appropriate pressure relieving devices available to support the staff and residents in daily activities. Advice is sought from, psychologists, occupational therapists, tissue viability specialists, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. The home has comprehensive medication policies and procedures for staff to use. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. Handwritten directions on the Medicine Administration Records (M.A.R.) did not have a witness signature. There is a register of staff who are authorised to administer medication. There were no extra stocks and the medicine trolley was clean and tidy. There was a good rapport between staff, residents and relatives, which was friendly and professional. Care was delivered in private and staff were seen to knock on doors and wait for permission before entering. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. Residents are well supported to take part in a range of social activities, which provides stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with opportunities to maintain their previous lifestyles. Residents are well supported to make choices and take control over their lives. Choices of nutritious and appetising meals are available to ensure individual dietary needs and preferences are met. The practices at mealtimes on the upstairs unit means that residents are unable to maintain their independence and mealtimes may not be an enjoyable event. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 14 EVIDENCE: A full time activities organiser works in the home providing a varied activities and events programme for residents. Included in the care planning process, residents’ social interests, hobbies, religious and cultural needs are assessed and reviewed monthly. This information is obtained by the activities organiser through a combination of recording life stories and talking to residents and their families. This then identifies what the resident would prefer to do and also what interests residents wish to continue to do. On the dementia unit activities are usually organised in small groups or on a one to one basis to ensure individual needs are being met. Notices about events stand out, are colourful as well as easy to read. Lots of pictorial prompts are used to help residents find their way around the unit. Information is available throughout the home letting visitors and residents know what’s going on in both units. Activities and forthcoming events are suitable and had been arranged in consultation with residents. The residents said that they are able to spend their days as they wish. They confirmed that they could get up and go to bed when they want and that visitors are always welcomed at any time. Information about advocacy is readily available in the home. The lunchtime meal was observed on both units. The downstairs dining room had the tables nicely set with tablecloths, appropriate crockery, cutlery and condiments. Residents were offered choices of juices, tea or coffee. The meal was served from a “hot” trolley and the choices were poached fish with parsley sauce, or salmon fish cake with peas, new potatoes, or chips. Choices for dessert were fruit crumble, Ice cream or yoghurt. The staff were attentive and gave assistance in a quiet unhurried manner. Residents said: “The food is always good” “We always have plenty to eat”. The tables on the upstairs unit were not set. Residents were not offered a choice of drinks; some did not have a drink throughout the meal. Residents who have some difficulty with eating were given a “soft diet” This consisted of mince, mashed potatoes, carrots, peas and gravy. Five residents have their meal sitting in the lounge as “they pinch other peoples food”. Some meals were left out of reach of residents, meals were getting cold, and one resident was stopped from using fingers to eat independently. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 15 Given the number of residents who need support and supervision to eat their meal staff could not give individual personal support however hard they tried. Residents said: “I don’t want that” “It would be alright if we could have some salt” Hebburn Court Nursing Home DS0000039411.V336571.R02.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. The complaints procedures are clear and easily accessed. This helps people to feel confident that their views are listened to and acted upon. Robust arrangements for Safeguarding Adults help to protect people from harm. EVIDENCE: The philosophy in the home is to address any concerns straight away and make sure that they are sorted out quickly and to everyone’s’ satisfaction. The manager has an open door policy and visitors and residents alike confirmed they knew what to do if they had a complaint. There is a detailed complaints procedure, which clearly sets out how and to whom to make a complaint. The procedure is available in the Statement of Purpose, Service User Guide and is displayed in the home. There have been seven complaints since the last inspection of 22 September 2006. Six have been resolved at home level and one was investigated and resolved by the Commission for Social Care Inspection. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 17 Staff are trained in Safeguarding Adults procedures so can recognise abusive situations and would know what to do if they suspected abuse. The home has a policy of updating training on a regular basis for all staff. There is also written information and guidance, as well as policies and procedures available in the home for staff to look at if they need guidance. Hebburn Court Nursing Home DS0000039411.V336571.R02.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): 19,20,21,24,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building is kept in an adequate state of repair and decoration. Further improvements will ensure that the environment is comfortable and safe for residents. EVIDENCE: The home has two units, which have separate lounges and dining rooms. There is direct and easy access to a very pleasant enclosed courtyard garden. The reception area has seating, a drinks machine, subtle music and plenty of information about the home, plus photographs of staff and residents taken during social activities. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 19 The lounge furniture on both units are showing signs of wear with some food spillage and old stains. Each dining room has round dining tables with slide and glide chairs. There is wheelchair and trolley damage to doors and walls through out the home. The upstairs unit has been decorated to reflect residents’ previous lifestyles. There is a ‘street’ with shop windows stocked with items relevant to the residents past, a ‘market place’ seating area, bedroom doors are brightly coloured to help residents recognise where they are and furniture is homely There is a ‘bar’ area that the residents like to use as a focal point that evokes memories and a quiet area with armchairs is provided. There are suitable toilets and specialist bathrooms and showers close to all resident areas. Many of these areas are showing signs of wear with damage to walls, worn flooring and water damage to the boxed piping. One bathroom was being used to store five hoists and there was damage to the plastic shower tray. On the upstairs unit one bathroom was particularly untidy and smelly. A used dirty flannel had been left in the shower tray. The shower tray was stained with some faeces and had not been cleaned after use. Bedrooms are personalised as residents wish. They are encouraged to bring small items of furniture, photos and ornaments with them when they come to live in the home. Some bedrooms are looking rather tired and would benefit from redecoration and new carpets. Profiling beds are provided for residents who need nursing care. On the day of inspection the home was generally clean, warm and bright. There was an odour throughout the day on the upstairs unit. The laundry facilities are separate from resident areas. There is sufficient equipment to deal with the laundering of all clothes although one dryer was broken. It was confirmed that new dryers were due to arrive later in the week. All of the light cords are knotted, grimy and cannot be cleaned on a regular basis. There are infection control policies and procedures in the home. Staff followed the procedures for disposal of clinical waste and confirmed that they had completed infection control training. Hebburn Court Nursing Home DS0000039411.V336571.R02.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. The current staffing levels is sufficient to meet the residents’ needs. A training programme is in place to make sure staff have the competence to care for the residents needs. The residents are kept safe and supported by clear recruitment procedures to prevent unsuitable people from working in the home. EVIDENCE: The units are staffed separately. There are registered mental health trained nurses, first level nurses, senior care and carers on duty over a twenty-four hour period. Some of the nursing staff hold a duel registration and three general trained nurses have completed a mental health diploma. There are senior care staff and care staff on duty There are sufficient ancillary staff employed over a seven-day period. These include, laundry, catering, administration, maintenance and an activity organiser. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 21 Six staff files showed that the recruitment procedures are followed. All contained evidence of completed application forms, interview records, two written references, terms and conditions of employment and induction records. Criminal Record Bureau and POVA First checks are carried out and these records are held securely. Personal Identification Numbers (P.I.N.) numbers of qualified nurses are checked with the Nursing and Midwifery Council to make sure nurses are registered. Evidence from the files and from discussion with staff confirmed that they have received training in moving and assisting, first aid, food hygiene, and infection control and fire safety. Other training includes, safeguarding adults, falls prevention, wound care, safe administration of medicines, promotion of continence, care planning, “Yesterday, Today and Tomorrow” which includes dealing with challenging behaviours. One member of staff acts as the “link” nurse for the control of infection. Hebburn Court Nursing Home DS0000039411.V336571.R02.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. The home has an experienced and proficient manager who provides leadership. This ensures the home is run in the best interests of people using the service. Clear systems for consultation and quality monitoring make sure that the views of residents are sought and acted upon. Residents personal accounts are well managed to ensure their best interests are protected. The health, safety and welfare of residents are being protected as far as reasonably possible. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager is experienced and competent to manage the home. She continues to update her knowledge to continually improve the service for the people who live in the home. The Company’s’ quality assurance system includes internal monitoring of complaints, maintenance, catering and domestic services. Storage and administration of medication is audited on a regular basis. Care plans are also internally audited with a number being randomly selected each month. The regional manager carries out regular audits and reports with actions and outcomes are available in the home. All residents have an individual balance record that is reconciled every week if any transactions have taken place. Monies are held in one joint non- interest making account. This practice is under review as some banks are now offering individual account facilities so that residents will then be able to gain interest on their money. The home holds an appropriate float and two signatures support transactions when a resident requires money. Staff have had training in safe working practices with records kept. Fire training is completed every three months for night staff and six months for day staff. A fire risk assessment is available and up to date. Water temperatures are recorded to ensure temperatures of 44 C is not exceeded. Accidents are clearly recorded and the manager completes monthly accident analysis to examine and track any trends. All internal maintenance checks are dated and signed. External service contracts were available and up to date. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 Requirement The registered persons must make sure that all handwritten directions on the Medicine Administration Records have two signatures. The registered persons must ensure that the lounge chairs are deep cleaned or replaced as part of the planned refurbishment programme. The registered persons must ensure that the damaged walls, doors and paintwork in all communal areas are repaired and repainted. The registered persons must ensure that all damage to bathrooms and toilets walls and floors is carried out and where necessary flooring replaced The registered persons must ensure that bedrooms are suitably decorated and furnished as part of the redecoration programme. The registered persons must ensure that all areas of the home are kept free from offensive odours and are clean at all DS0000039411.V336571.R02.S.doc Timescale for action 01/08/07 2 OP20 23 01/11/07 3 OP20 23 01/11/07 4 OP21 23 01/11/07 5 OP24 16,23 01/01/08 6 OP26 13,23 01/08/07 Hebburn Court Nursing Home Version 5.2 Page 26 times. The light cords must be renewed and be easily cleaned on a daily basis. 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 OP15 Good Practice Recommendations The dependency levels should be constantly reviewed to make sure that sufficient staff are available on the upstairs unit at meal times. Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Hebburn Court Nursing Home DS0000039411.V336571.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!