Inspection on 24/08/06 for Hedgerows Nursing Home

This inspection was carried out on 24th August 2006.

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

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

Other inspections for this house

Hedgerows Nursing Home 20/07/07

Hedgerows Nursing Home 19/01/06

Hedgerows Nursing Home 14/07/05

Hedgerows Nursing Home 07/12/04

Hedgerows Nursing Home 30/07/04

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Paradise Lodge

Grangewood

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Hedgerows Nursing Home 256a Ongar Road Brentwood Essex CM15 9DX Lead Inspector Helen Laker Key Unannounced Inspection 08:00 24th August 2006 X10029.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 Hedgerows Nursing Home DS0000015538.V300423.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 and Care Homes for Adults 18 – 65*. 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. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hedgerows Nursing Home Address 256a Ongar Road Brentwood Essex CM15 9DX 01277 202270 01277 215520 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) Outlook Care Mr Simon Chua Kim Chuan Care Home 40 Category(ies) of Dementia - over 65 years of age (6), Learning registration, with number disability (7), Old age, not falling within any of places other category (33), Physical disability over 65 years of age (33) Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Nursing and personal care to be provided for up to 33 Older People. Nursing and personal care to be provided for up to 7 people with a Learning Disability. Nursing and personal care to be provided for up to 33 Older People with a Physical Disability. Nursing and personal care to be provided for up to 6 people with Dementia over the age of 65 years. Maximum number to be cared for shall not exceed 40. Date of last inspection 19th January 2006 Brief Description of the Service: The Hedgerows is a purpose built bungalow complex sited around a courtyard. Two of the bungalows provide for fourteen service users one provides for twelve service users. Each one has its own attached small well-maintained garden. The bungalows are situated within the grounds of Highwood Hospital, close to the centre of Brentwood. The location is convenient to a local bus service and benefits from having a small parade of shops close by. At present the home provides for seven learning disability clients, six service users with dementia, and thirty three physically disabled older people with nursing needs. The home has previously reduced its occupancy to a total of forty service users. At the time of this report, one bed was contracted by the Primary Care Team for transitional service users prior to permanent placement in residential or nursing care homes or community based home care. The home was first registered in March 1994. The Service User Guide and Statement of Purpose have been reviewed and the residents and their representatives have been provided with this information and the acting manager stated that the home would provide them with Commission for Social Care Inspection reports too. At the time of this report the acting manager supplied a scale of the homes charges and fees these range from £600.00 to £1097.00 per week Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection which took place over seven hours with one inspector in the home. This unannounced inspection, was undertaken on the 24th August 2006 with the assistance of the acting manager. The inspection took place over two days, one spent in the home viewing records and files. There was a tour of the grounds and an inspection of records and documentation. Time was spent discussing the care of the service users. Further feedback was also received from service users and care staff through completed surveys, telephone contact and discussion. Survey responses have been included in the relevant sections of the report. A pre-inspection questionnaire and other reports and correspondence provided by the acting manager was also used as evidence to inform this report. The present acting manager in charge of the day to day management of the home and staff were spoken with. Thirty two National Minimum Standards were inspected on this occasion, twenty seven overall outcomes were met and there were five requirements detailed in the full report. Discussion of the inspection findings took place with the acting manager in charge of the day to day management of the home at the end and throughout the inspection, guidance was given. What the service does well: What has improved since the last inspection? A lot of improvements to the internal areas of the home have been undertaken including all bungalows being completely redecorated. New fixtures and fittings have been purchased such as recliner chairs and dining room furniture. It was noted at the last inspection that “Person Centred Planning” will be introduced to ensure service users plans are more involved and they can take ownership and responsibility for their own self. This is now fully in place and seen as good progress. The home operates a work based induction programme which is competency based and has been reviewed to TOPSS standards The present acting manager is currently awaiting registration following her application being submitted to the CSCI. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a comprehensive Statement of Purpose and Service User’s Guide. Present and prospective service users and their supporters are given adequate information about the home so that they can make informed choices. The admission procedure does include an adequate assessment which ensures that service users needs can be met. The home provides a caring environment where visitors are made welcome. EVIDENCE: The home has a comprehensive Statement of Purpose and Service User’s Guide. The statement of purpose incorporates all recommended criteria. The service user guide is user friendly, in a relevant format and provides an Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 9 overview of the home and services available. Both documents have been reviewed to clarify the home categories and provision of service to transitional residents. The home has recently varied it’s registration to take up to 6 service users with dementia. A sample of care plans seen demonstrated that a full assessment has generally been undertaken prior to admission. Those service users admitted through care management arrangements included assessments from the relevant authorities. This was seen for two of the most recently admitted service users whose assessments were completed. One transitional bed space is based in one bungalow to provide dedicated space. Service provision and evaluation of staff competence regarding short stay care has been developed. Specific procedures and policies promoting independence and mobility were discussed previously and are in place. Service user feedback and consultation with the placement officers and discharge coordinator are in place to support ongoing development of the service. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user has an individual person centred plan and service users are supported to take risks as part of an independent lifestyle via a process of assessment. While improvement has been made to the care planning process some further progress is required to ensure that service users needs are met. The health needs of service users are well met although better documentation would ensure clarity of needs. Medication administration and recording was being addressed appropriately. Personal support is provided in a way that promotes dignity. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 11 EVIDENCE: It is noted that comprehensive person centred plans previously in draft form are now finalised and have been implemented. Evidence of five service user care plans indicated that their basic health, personal and social care needs are recorded within an individual plan of care. Instructions for staff to meet service users’ care needs were not on all occasions clear and comprehensive. Care plans did not always evidence service users’ or relatives’ involvement and those seen were reviewed on a monthly basis. Daily recording requires improvement to ensure they detail the welfare of the service user, how they spend their day and the progress of the care plan. Risk assessments were available for some service users but were also noted to require more detail and include potential complications of the risk. Care plans did not always include photos, consultation on restraint agreements, likes and dislikes, evaluation of care needs thorough monthly reviews and a more standard approach taken. The manager was advised of these issues during the inspection and stated that training is planned. Care plans evidence that service users are enabled to access all community health services. The inspector was informed that only trained staff administer medication. Completed drug histories should still refer to dose changes on the form. All individual entries on the drug sheets should be signed by the transcriber and checked for accuracy. The dose form and strength of medication should be clearly recorded on treatment charts. Covert medication procedures are now clearly documented in care plans where applicable and policies and procedures reviewed and updated. This issue was highlighted at the homes previous inspection. The home also has an agreed contract for adequate disposal of waste medication. Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. However more prominence as appropriate should be based on ensuring service users views regarding afterlife issues are recorded in plans of care. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities take place and service users are generally happy with the choices in routine available to them Visitors are made welcome and overall the service users rights and responsibilities are recognised in their daily lives. EVIDENCE: The home has an activities organiser but the inspector was informed that plans are in place to restructure the activities hours by placing recruited activity workers on each bungalow for a minimum of 20 hours a week. Additional activities are organised by staff presently. A wide range of activities are Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 13 available inside the home and in the local community. The home has access to a minibus and disabled taxi service. A light and sensory room is available. Activities of daily living are documented in the care plans. The Manager stated that the home operates an open visitor’s policy and encourages relatives to be involved in the home. There is a relatives’ group which meets regularly. The home promotes the use of an advocacy service for its service users. An advocate chairs the service users’ meeting and is involved in service users’ care reviews where no relatives are available. There was evidence of service users personalising their rooms to their individual tastes upon a tour of the premises. Each bungalow has its own kitchen facilities and a cook. Individual nutrition assessments are undertaken on admission. Nutrition records have not been maintained on all bungalows and regular checks on the refrigerator and freezer temperatures are maintained. All food is temperature checked before serving. All three kitchens have been refurbished and service users spoken with all said the food supplied was to a good standard and choices were always available. Menus were on display on all bungalows. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has effective procedures in place to ensure that service users are protected from abuse, neglect and self harm. EVIDENCE: The home has an appropriate complaints procedure which is displayed in each bungalow. Records are kept in each bungalow and a master complaints log is maintained at the Proprietor’s head office to monitor trends and incidences throughout all the group’s homes. This had not been kept up to date and was discussed at the homes last inspection. Up-to-date protection and whistle blowing policies are available in each bungalow. Positive response workshops are available for staff. There are procedures in place for dealing with aggression and challenging behaviour. Staff have received training on abuse on induction and protection of vulnerable adults training for staff has either been undertaken or is planned. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Hedgerows was clean, bright and well maintained and provided the service users with safe, homely and comfortable surroundings. Major improvements have been made to the décor of the home. Not all staff are totally aware of the fundamental concepts of restraint. EVIDENCE: Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 16 The home’s accommodation is provided in three self-contained bungalows – “Hawthorn, Bluebell and Foxglove”. Each provides a homely environment for the service users. The surrounding grounds are well maintained with seating provided. The Manager meets with the Estates Manager regarding all maintenance of all the bungalows. Records of maintenance are maintained. Each bungalow has a dedicated lounge and dining areas and carpet has been replaced in these areas in Foxglove and Bluebell bungalows previously. All three bungalows have been redecorated and new recliner chairs and dining room furniture have been purchased. In addition tracker hoists have been fitted into all rooms and new slings purchased for individual service users where required. Transitional service users have their own dedicated accommodation with their own communal areas Each bungalow has two bathrooms and a shower room and six toilets. None of the bedrooms have ensuite facilities The bungalows are purpose-built. They all have a service user call system, hoists and lifting and handling equipment. Hawthorne bungalow has a sensory garden and a sensory room has also been developed. The accommodation in terms of bedroom space meets the standards for homes registered before August 2002 All service users’ bedrooms were seen to be personalised to individual tastes and have doors with locks and some were equipped with lockable facilities. The home provides adjustable beds, allocated by service user’s needs. The screening in double rooms did not really ensure the dignity and privacy of service users but was adequate. Service users were being restrained with lap belts in chairs with inadequate documentation in their plans of care or no risk assessment. This was discussed with the manager at this inspection as it was noted at the last also. All bungalows were seen to be bright and airy. All rooms were naturally ventilated and centrally heated and had adequate lighting. Health and safety inspections are carried out by the NHS Estates Department. Hot water monitoring is carried out on a regular basis. All bungalows were seen to be clean and tidy and odour free. Adequate laundry and sluice facilities are provided. Infection control procedures are in place and regularly reviewed. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels are currently maintained to meet the needs of service users. Recruitment practices currently are poor and have major shortfalls which need addressing. Staff training is appropriately developed and undertaken to provide a competent work force. EVIDENCE: Hedgerows are complying with the staffing notice agreed in March 2002 by South Essex Health Authority, the previous regulatory authority. The Manager reviews skill mix and dependency levels as an ongoing process. Agency and bank staff are currently being used in high quantities to cover, training for staff vacancies, holidays and sickness. Of the seven staff records reviewed it was noted that some documentation was missing and records for recently recruited staff were not available to inspect. The Inspector was informed that Criminal Record Bureau checks have been obtained but were not available to inspect. There was evidence of inductions Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 18 but no job descriptions and current contracts were noted to not be signed or dated or even renewed in some cases. The process regarding agency and volunteer recruitment and CRB checks was discussed. Attention should be paid when recruiting, to addresses for references, incomplete application forms, comprehensive work history and proof of identity. The manager was advised that staff members should not start work at the home until all relevant recruitment checks have been completed. The manager was also advised of current immigration requirements and regulations and the recruitment checks required for agency staff. There was minimal evidence of appropriate checks for agency staff working at home. She was advised to inspect other staff personnel records to ensure that the home was compliant with legal requirements. The home operates a work based induction programme which is competency based and has currently been reviewed. Appraisals are used to assess individual training needs. The home’s pre-inspection questionnaire evidenced that staff receive foundation and pertinent training. The Manager is ensuring the home’s induction programme is to TOPSS standards. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is guidance and direction to staff and the home does overall have in place practices that will promote and safeguard the health, safety and welfare of the people using the service. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 20 EVIDENCE: The current acting manager is a qualified RGN and holds the Diploma in General Nursing and a post graduate Diploma in Health Services Management. She has twenty-seven years nursing experience of which thirteen years have been at management level. Her application for registration is currently being processed by the CSCI. Outlook Care has achieved ISO9002 accreditation and Investors in People. The Proprietors have in place a steering group for quality assurance monitoring. The inspector was informed that the home holds audits every six months on local standards and an advocacy forum is held on a monthly basis. The home has a development plan and there are plans to introduce service users and stakeholders’ quality questionnaires but as yet results of these have not been forwarded to the CSCI. An appointee from the Proprietor’s Head Office is available for service users who cannot manage their finances. Generally, finances are managed by service users’ families. Records and receipts are kept for all transactions for each service user. Supervision planning, forms and records were not all clear and up to date. Staff are aware of supervision. Induction programmes are provided for all employees within the first six weeks. The inspector was informed that new staff are generally on a six month probation and supervised and reviewed on a regular basis. The home does not have any volunteers but are aware of the checks required if any are taken on in the future. It is recommended that all staff receive a minimum of six structured supervisions and one appraisal annually. Up to date appraisals were seen for six staff. Records seen throughout the inspection were generally well kept but there were shortfalls in areas. Some have been commented on throughout this report. The Manager is fully aware of her responsibilities for health and safety and staff receive regular training on health and safety. Restraint training must be addressed as service users were being restrained with lap belts in chairs with inadequate documentation in their plans of care and assessments. Health and safety checks are regularly carried out by NHS Estates Management Team. Safety certificates were available for gas, electric and fire, call systems, hoists and prevention equipment. Regular checks were seen for hot water and fire equipment. Regular fire drills were seen to be being carried out. A lot of this was covered at the homes previous inspection. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 21 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 3 2 X 3 3 4 X 5 X 6 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 3 21 3 22 3 23 3 24 2 25 3 26 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 3 37 2 38 3 Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) 17(1)(a)(b) Requirement A detailed service user plan of care must be drawn up including consultation with service user families and significant multidisciplinary personnel, to be reflected in the care plan and reviewed comprehensively monthly. (Previous timescales of 27th Feb 2006 not met.) Risk assessments must be carried out for the example: -use of bed rails and includes details of potential implications of their use for the service users within individualised plans of care. This with regard to all other risk assessments formulated especially those at risk of falls, pressure sores and those for COSHH and environmental health and safety issues. (Previous timescales of 27th Feb Timescale for action 02/10/06 1A. OP7 13 (4) & 13 (8) 02/10/06 Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 23 2006 not met.) 2. OP15 17 (2) Schedule 4 A record must be kept of food prepared for service users, including special diets and made available for inspection. Service users must not be restricted with lapbelts permanently for any reason or be subject to any form of restraint. Consideration must be given to the issue of formulating individual plans within a riskmanaged strategy. (Previous timescales of 27th Feb 2006 not met.) The registered person must operate a robust and thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. Records required by regulation for the protection of service users and for the effective and efficient running of the business must be maintained, up-to-date and accurate. (Previous timescales of 27th Feb 2006 not met.) 02/10/06 3. OP24 13 (7) & (8) 02/10/06 4. OP29 7, 9, 19 (1) to (7) Schedule 2 02/10/06 5. OP37 17 (1)(3) 02/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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. Hedgerows Nursing Home DS0000015538.V300423.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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