Inspection on 12/05/06 for Herons Park Nursing Home

This inspection was carried out on 12th May 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

Herons Park Nursing Home 14/02/08

Herons Park Nursing Home 23/05/07

Herons Park Nursing Home 23/11/05

Herons Park Nursing Home 24/08/05

Herons Park Nursing Home 31/03/05

Herons Park Nursing Home 14/02/05

Herons Park Nursing Home 12/01/05

Herons Park Nursing Home 09/11/04

Herons Park Nursing Home 14/10/04

Herons Park Nursing Home 21/04/04

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

CARE HOMES FOR OLDER PEOPLE Herons Nursing Home, The Heronswood Road Spennells Wood Kidderminster Worcestershire DY10 4EJ Lead Inspector Y South Unannounced Inspection 12th May 2006 09:15 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 Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 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. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Herons Nursing Home, The Address Heronswood Road Spennells Wood Kidderminster Worcestershire DY10 4EJ 01562 825814 01562 753656 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) Regency Old Homes Plc Mr Salum Naujeer Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58), Physical disability over 65 years of age of places (58) Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Pre-admission assessments will specifically address mental health needs of potential service users and the home will not admit any person identified as having dementia illness. The home may accommodate 7 named current service users who have dementia illnesses. When the service users plans are reviewed (i.e. at least monthly) an assessment will be made as to whether or not there are any dementia needs and, if so, whether they are being met appropriately in the home and how. Commission for Social Care Inspection will be notified of any resident service user who develops a dementia illness after their admission. 23rd November 2005 2. 3. 4. Date of last inspection Brief Description of the Service: The Herons Nursing Home provides nursing and personal care for a maximum of fifty-eight people of either sex, over the age of sixty-five years who have needs associated with old age and physical disabilities. The home has a variation enabling it to accommodate named service users with a dementiatype illness. This establishment is situated on the outskirts of Kidderminster close to local amenities and the public transport system. The premises are purpose built with en-suite facilities throughout. There are eighteen single bedrooms and twenty double bedrooms. Lounge and dining facilities are provided on each floor. A shaft lift facilitates the movement between floors. The building has good parking facilities and a small garden. Regency Old Homes Plc, for whom Dr Hatif Himoud is the responsible individual, owns the home and the registered manager is Mr Sam Naujeer. Information regarding the home is available in the Statement of Purpose, The Service User’s Guide and Inspection reports. These documents are available on request from the home. Information received from the registered manager on 27.04.06 stated that the charges for residents in the Social Services and Continuing Care banding were £458 for a single room and £447 for a shared room. Privately funded places cost £480. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection focused on the core care standards, requirements and recommendations made in the previous inspection report and issues that had been brought to the attention of the Commission for Social Care Inspection Evidence has been gathered from the contact made with the home since 23rd November 2005, questionnaires that were distributed to residents, relatives and health care professionals and a visit to the home that extended over nine and a half hours. During the visit the inspector observed some of the home, work practice and spoke with some of the residents and staff and the manager and responsible individual. What the service does well: What has improved since the last inspection? The standard of care planning continues to improve and provide more detailed information to assist the staff and monitor the changes in the welfare of residents. Recruitment practice has improved to ensure pre employment checks are carried out and only suitable staff are appointed. Although there are still issues regarding the standard of the laundering and missing buttons the laundry itself is better organised and cleaned. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 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. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home only offers to accommodate and care for people whose needs can be met. EVIDENCE: Evidence was received in the questionnaires that were completed and returned to the Commission for Social Care Inspection, and from assessment of residents’ records, that someone had visited them from the home and a detailed assessment of their needs had been undertaken before they had been offered a place. During the inspector’s visit it was observed that people who were making inquiries in behalf of a prospective resident were correctly advised and an appointment was made for an assessment to be undertaken. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 9 The staff who were interviewed were unaware of the content or purpose of the Statement of Purpose or the Service Users Guide. They were advised to rectify this. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have access to most of the up-to-date information necessary to enable them to provide the care the residents’ need. Small discrepancies in the implementation of the medication procedure could put residents at risk. EVIDENCE: Records were assessed and care plans were available and detailed. They had been completed and were regularly reviewed in consultation with the resident or, with the resident’s consent, their relative. Where a gender preference existed for personal care this was recorded and respected. Staff were aware of the content and availability of these documents and one person when asked was able to accurately state their value and use to the resident and staff. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 11 One resident needed a care plan to describe the care she needed when she became distressed and challenging. Some improvements were needed in the following areas: • Assessments of pressure care needs should be carried out at least monthly and more frequently when high risks had been identified. • When residents were found to have bruises it should be evident that an investigation had been conducted as to the cause and future prevention. • The personal hygiene monitoring records should be fully maintained. • Moving and handling assessments should be reviewed monthly and more frequently when changes and risks are identified. Five GPs and thirteen residents and their relatives returned completed questionnaires to the Commission for Social Care Inspection. The GPs expressed their high opinion of the home and the care provided. Comments included; “Liaison regarding patients’ care needs was excellent.” “The manager runs a good service.” “This is an excellent nursing home.” “I think this is the best run care home, with the highest standards of compassion, care, knowledge of patients conditions.” “The staff team are well informed.” Residents and relatives expressed their positive opinions of the health care provided and a resident endorsed this during the inspector’s visit to the home. Issues had been brought to the attention of the Commission for Social Care Inspection concerning dressing techniques, moving and handling techniques, medication administration and pain control and feeding techniques. The Infection Control Nurse Consultant had been consulted by the Commission for Social Care Inspection and had accepted the verbal description of the technique used in the home. She had offered to visit the home and observe their practice and provide training. The manager was urged to take advantage of this offer at the earliest opportunity. It had been alleged that staff were not following moving and handling care plans, as it took longer to use the hoist than moving residents manually. As previously stated full assessments needed to be undertaken regularly. Staff said that they always followed the plans and said that the manager was very observant and insistent that residents were lifted correctly. Those staff who were not directly concerned with care said that from their observation residents always appeared to be lifted safely. The inspector observed that techniques could be improved. The manager had received training updates through ‘Arjo’ and the most recent certificate seen was dated February 2004. He was about to undertake a more in-depth course through ‘Business Link’. He took the lead in cascading training to all staff. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 12 It had been alleged that untrained staff were administering medication dispensed by the trained staff. The inspector spoke with three staff on this subject. They were all aware of the correct procedure and were adamant that when medication was administered by a trained nurse and carer it was done under the direct supervision of the trained nurse and care staff did not administer medication unobserved. The staff were aware which residents suffered from pain and assured the inspector that an appropriate response was made. There was always a trained nurse on duty on each floor and prescribed medication could be given whenever needed. Most medication was stored appropriately. There were some controlled drugs that the manager said had been brought in to the home by a relative. There needed to be a record of these and they should be destroyed, as the resident did not need them. Two entries had been omitted in a resident’s Medicine Administration Record and no explanation was recorded. One box of medicine was labelled to be given ‘as directed’. This is not acceptable. Such medicines should be returned to the pharmacist and the GPs should be asked to record more explicit directions on the prescription. A loose card of tablets was found in the trolley with no label identifying the owner or the doctor’s instructions. Eleven staff had received training updates in medication in December 2004 and the manager said that he planned to organise annual up-dates for all trained staff. It had been alleged that a resident was being fed against her will. The inspector assessed the person’s records and spoke to five staff. The records indicated that the resident needed a lot of encouragement and support to eat and drink. The staff confirmed that there could be a great reluctance to eat and drink but they were encouraging and persistent. They confirmed that they were aware of the fine line between encouragement and bullying (abuse) and had never seen any behaviour from any staff that concerned them. They were clear on what they should do if they had any concerns. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 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 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. Residents have access to activities and stimulation if they wish to participate. Their religious needs are known and supported. Visitors are welcomed and supported. A choice of food is provided that meets dietary needs and preferences and is enjoyed by most residents. EVIDENCE: Residents and relatives indicated in the questionnaires that activities were provided and they were able to participate if they wished. An activities organiser was employed and she arranged her day so that she spent the morning on the top floor where one to one contact was preferred and during the afternoons she arranged group activities on the ground floor. One relative recorded in the questionnaire; “It is a pity that staff don’t find the time to chat to clients.” During the inspector’s visit and lot of interaction was observed between staff and residents. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 14 The care plans demonstrated that individual preferences and wishes were known regarding family links, activities, outings and religious needs. Some people were able to go out with friends and relatives. Some people went regularly to the church of their choice. Religious leaders visited the home to see their parishioners. Visitors were welcome to visit throughout the day. They were made to feel at home and were supported by staff. One relative suggested that it would be nice to have a small area to themselves for tea and coffee making facilities so that they could make and have drinks with their relative. This suggestion was passed on to the manager. The records of food provided demonstrated that a choice was offered and appetites were monitored. The inspector spoke with three residents but only one was able to communicate effectively. None-the-less he confirmed that he had enjoyed his lunch and the food was ‘lovely’. Questionnaire responses indicated that people ‘always’ or ‘usually’ enjoyed their meals. A vegetarian said that he/she received meals accordingly. Several people needed their food softened or liquidised and a member of staff confirmed that the foods were arranged separately and as attractively as possible on the plates. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An acceptable recruitment procedure is used to ensure suitable staff are appointed. Staff are aware of the vulnerability of residents who live in the home. They have access to information regarding the Protection of Vulnerable Adults but would benefit from formal training in this subject. A requirement to this effect had not been met. EVIDENCE: A complaints procedure was available in the home and had been distributed in the Terms and Conditions of Residence to all residents or their relatives. Questionnaire responses indicated that people were usually aware who to raise their concerns with. The staff who spoke to the inspector knew the correct advice to give to anyone who wished to make a complaint. A range of concerns had been brought to the attention of the Commission for Social Care Inspection and was currently being investigated by them and by the Adult Protection Department. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 16 Following the inspector’s previous visit it was required that staff receive training regarding the protection of vulnerable adults. During the inspector’s most recent visit the staff demonstrated their awareness of the vulnerability of the residents and the availability of policies, procedures and manuals concerning their safety and well-being. It is still required that more structured training is received from an external trainer. During the previous inspection it was identified that checks were not always made and responses received before newly appointed staff were confirmed in their post and commenced their duties. A requirement was made that this did not happen. Records were assessed for four staff during the inspector’s latest visit and it was observed that the relevant documentation was available. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 17 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 the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to live in a clean well equipped home that suits their needs and seeks to control the risks of cross infection. EVIDENCE: A full tour of the home was not conducted. However the areas the inspector walked through were clean and free from unpleasant smells. One questionnaire response was; “The home is perfect for cleanliness.” All others agreed that the home was always fresh and clean. At the time of the inspector’s previous visit it was observed that improvements were needed regarding the cleaning of the laundry and a requirement was made to this effect. During this inspection it was observed that the laundry was acceptable and a cleaning routine had been established. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 18 It was observed that liquid soap and disposable towels were available in bathrooms and toilets and the staff confirmed that personal protective equipment was always available. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Suitable staff are recruited to meet the needs of the residents. However at times staff levels fall below what is planned and care provision is adversely affected. Training is provided. However individual training records are not maintained and training and development profiles are not available. Therefore it is not possible to draw up a clear programme to meet the prioritised training needs of individuals. EVIDENCE: It had been alleged that there were frequently insufficient staff on duty during the mornings to help residents with their personal hygiene and care needs. Acceptable duty rosters were submitted to the Commission for Social Care Inspection prior to the inspector’s visit. On the day of the visit there was one trained nurse and five care staff working on the top floor where the most dependent residents live. Four of these commenced their duties at 8am and the other two started at 9am. This hour’s delay may have an affect on the provision of care dependant on the wishes and needs of the residents. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 20 On the ground floor there was one trained nurse and four care staff. They all commenced work at 8am. One person came on duty at 9am and was described as the ‘tea lady’. The manager said that this person assisted with personal care as well as serving drinks to residents. Staff moved between floors and helped in other areas as available and needed. All staff that spoke to the inspector confirmed that if all rostered staff were on duty there were no difficulties, however problems arose when staff went sick giving short notice. Some ‘bank staff’ were already employed and some staff were willing to work more than their contracted hours but it could be difficult or impossible to find someone else to cover the duties. It was suggested that a larger bank of relief staff would resolve the problem. However the manager said that he was waiting for CRB and POVA clearance so that two newly appointed staff could start work and believed this would resolve the difficulty. It is not acceptable for staffing levels to fall below the level needed to meet residents’ needs. If the staff team is unable to provide sufficient cover agency staff must be used. Discussions were held with five staff and they were clear regarding their duties and responsibilities. Residents and relatives described the staff as; ‘Very helpful’, The staff have always done whatever I asked. ’They are always around so you can see them or speak to them’. ‘Kind and friendly.’ One resident said in the questionnaire “Sometimes they ignore what I have said. I asked for an extra blanket as I was cold and wasn’t given one.” This response was brought to the attention of the manager who said that the resident had been given the blanket but unfortunately had forgotten. The staff files that were assessed contained all relevant information. An excellent form had been implemented that clearly indicated what training each person had undertaken last year and this made it easy to ensure all staff had received at least three days training. However a full individual training history was not available. Without a chronological training history for each person it is not possible to do a training analysis of the full team and draw up a training programme for the coming year. This had been required after the inspector’s previous visit and had not yet been complied with. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager is both experienced and well qualified. People find him approachable. The lack of a deputy raises the risk that clinical demands may have an adverse effect on managerial duties. Monitoring of standards and development of the service is adversely affected as the quality assurance system has not been implemented, regular staff meetings are not held and supervision sessions with staff are not taking place at the frequency required. The lack of comprehensive fire safety training and the presence of a trained first aider puts people at risk in the home. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 22 EVIDENCE: The home is run by an experienced and well-qualified manager. Recently allegations had been made to the Commission for Social Care Inspection concerning his practice. Investigations had found no evidence to support the allegations with the exception of the concern regarding staffing levels. The manager had recently completed a training course through Business Link titled ‘Maximising the Health of the Elderly’. It was observed that visitors and staff found the manager approachable and supportive. Those staff interviewed described him as a ‘good manager’, ‘responsive’, ‘good hands on practitioner’, ‘good mentor’. Every one said that he could get angry and shout at times and this could frighten some staff although “he did not mean to”. Staff meetings were said to be held ‘when necessary’ but not regularly. A quality assurance programme had been developed but not implemented. This should be addressed. A relative suggested in her questionnaire that a review of residents’ needs held by appointment with relatives every three to six months would clear up problems and encourage relatives to become more involved in the residents’ lives. This suggestion was passed onto the manager. The home manages the personal monies for some residents. It was observed that the monies were kept securely and appropriate records were maintained. Staff received some formal supervision but the records that were seen did not provide evidence that this was taking place every two months. A programme needs to be developed and implemented to address this. The home no longer employs a deputy and the manager has no current recruitment plans. The situation will need to be closely monitored as the manager’s role is principley to manage not to regularly and frequently work as one of the trained nurses. Discussion with the handy man confirmed that the programme of servicing and maintenance continues to be implemented. The fire log indicated that fire safety systems were routinely checked. At the time of the inspector’s previous visit it was recommended that a monitoring tool should be used to ensure all staff participated in up-dates of Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 23 fire safety training and drills at the frequency recommended by the Fire Authority. This recommendation had not been accepted and is therefore repeated. Although the records indicated that four fire drills had taken place this year with an average attendance of ten staff, several of who had attended more than one event, and forty-three staff had attended a course from an external trainer, the home employs more than fifty staff. Therefore it is clear that not all staff have received training up-dates All staff should receive training up dates in this subject every three months and participate in at least one drill each year. It is therefore essential that participation be monitored in order to manage the attendance. It was required following the inspectors previous visit that a qualified first aider should be on duty at all times. During this last visit the manager said that all staff had undertaken the oneday Emergency First Aid course. He was informed that either a risk assessment should demonstrate that this met the needs of the home or the four day course must be undertaken by all senior staff to ensure a trained first aider be on duty at all times. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 2 3 2 Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 25 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 12, 13 Requirement Full detailed assessments regarding pressure care and moving and handling should be undertaken at least monthly so that accurate information is available on which to review a care plan. Care plans should be available to advise and guide staff on how to respond to residents who have challenging behaviour. The management of medication should be improved in respect of the following: • A record should be made of all medication received into the home and if not required by the resident should be disposed of and a record made. • If medicines are not given as prescribed an explanation must be given. • Medicines must always be kept in the container dispensed by the pharmacists and having the pharmacist’s label. Timescale for action 30/06/06 2 OP7 12, 13 30/06/06 3 OP9 13 31/05/06 Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 26 4 OP18 12, 13 Clear records must be maintained of all investigations into bruises that residents develop and the Commission for Social Care Inspection be notified under Regulation 37 if appropriate. Staffing levels must be maintained regardless of staff sickness. Agency staff must be used if the home team cannot provide the cover needed. All staff must have an individual training and development assessment and profile. A training analysis and training needs programme must be available in order to identify, prioritise and meet training needs. Training must be arranged for all staff in the recognition and response to suspicions of abuse and protection of vulnerable adults. An effective quality assurance and quality monitoring system, based on seeking the views of residents must be implemented to measure the home’s success in meeting the aims, objectives and statement of purpose of the home. All care staff must receive formal supervision at least six times a year that covers: • all aspects of practice • Philosophy of care in the home • And career development needs. 12/05/06 5 OP27 18 12/05/06 6 OP30 12, 18 01/11/06 7 OP30 12, 18 01/11/06 8 OP33 24 01/11/06 9 OP36 18 01/08/06 Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 27 10 OP38 12, 18 All staff must receive up-dated 01/09/06 fire safety training every three months and attend at least one fire drill every year in accordance with the advice given by the Fire Authority. Attendance must be monitored to ensure no staff are omitted. A qualified First Aider (four day first aid at work course) should be on duty at all times or a risk assessment should demonstrate that the one day Emergency Aid course met the needs of the home. 01/01/07 11 OP38 12, 18 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 OP1 Good Practice Recommendations All staff should be aware of the contents of the Statement of Purpose and the Service Users’ Guide and their purpose. Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Herons Nursing Home, The DS0000004116.V289247.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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