Inspection on 14/02/08 for Herons Park Nursing Home

This inspection was carried out on 14th February 2008.

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

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 23/05/07

Herons Park Nursing Home 12/05/06

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 Park Nursing Home Heronswood Road Spennells Wood Kidderminster Worcestershire DY10 4EJ Lead Inspector Chris Potter Unannounced Inspection 14th February 2008 09:30 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 Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Herons Park Nursing Home Address Heronswood Road Spennells Wood Kidderminster Worcestershire DY10 4EJ 01562 825814 01562 753656 heronspark@btconnect.com www.royalbay.co.uk www.royalbay.co.uk Regency Old Homes Plc 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) Sandra Jayne Packwood 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 Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 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 (ie 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 May 2007 2. 3. 4. Date of last inspection Brief Description of the Service: Herons Park 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 registration variation enabling it to accommodate named service users with a dementia-type illness. It does not offer a service to new people with dementia illnesses. 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 and twenty double bedrooms. Lounge and dining facilities are provided on each floor. A shaft lift facilitates the movement between floors. There are good parking facilities, a small garden overlooking the adjacent park and an enclosed courtyard garden. Regency Old Homes Plc, for whom Mr Russell Leonard Wilson is the responsible individual, owns the home. The registered manager is Mrs Sandra Packwood. The email address for the home is heronspark@btconnect.com 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. The fees for the home are between £550 and £650, this was correct at the time of the inspection for more up to date information please contact the home Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 5 direct. Additional charges are made for chiropody, hairdressing and newspapers. Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Even though the home received an “adequate” rating it was a positive inspection and comments received from the residents, staff and relatives were complimentary. The area which the home, need to address to improve the quality rating was care plan documentation and complaint management. This was a key unannounced inspection – this is where we look at a wide range of areas. The inspection was carried out over two days on the 14th and 18th of February 2008. We spent a total of 12 hours in the home. To help us plan for the inspection we looked at pre – inspection information requested earlier in the year, this included the Annual Quality Assurance Assessment (AQAA). A range of evidence was used to make judgements about this service. This includes: information from the provider, staff records kept in the home, medication records, discussion with people who use the service, discussions with the staff team, discussion with the deputy manager, tour of the premises, previous inspection reports, quality assurance process, and observation of care experienced by people using the service. Even though the home received an “adequate” rating it was a positive inspection and comments received from the residents, staff and relatives were complimentary. The area which the home need to address to improve the quality rating was care plan documentation, which does not effect the overall care of the residents. Since the last inspection the home has received several complaints, mainly from anonymous sources, two have which were referred to the lead agency for safeguarding adults. The home has co operated with the investigations (see complaints section of the report). What the service does well: The home provides a pleasant environment with excellent facilities for the residents. The providers are in the process of further developing the gardens for the residents to enjoy when the weather permits. Prospective residents and or relatives are provided with the appropriate information about the home to assist them with their choice. The home employs an activities organiser who is clearly dedicated to providing residents with a varied range of suitable activities. The activities are Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 7 individualised for each resident to meet their needs. Support is regularly given by the local vicar and minister for those who wish to attend religious services. Comments from staff, relatives and residents were most complimentary about the activities organiser and her enthusiasm for the role. The staff ensure that the residents respect and dignity is promoted, the residents and relatives confirmed this. The laundry provision for the home was complemented by the residents and relatives. The menu demonstrates that there is a good choice of nutritional meals from which residents can make their selection. Special diets and preparations are also provided according to needs and wishes and assistance is given where needed. The management and organisation of medication was well organised. What has improved since the last inspection? What they could do better: Care plans have improved since the last inspection, however not all staff are consistently reviewing and updating the records. The home should develop a system to ensure that all the nurses are clinically updated, and a supervision program is introduced for the nurses, Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 8 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. Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 9 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 Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 10 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): Standards 1, 2,3 (the home does not provide intermediate care therefore standard 6 does not apply). Quality in this outcome area is good. Prospective residents and their representatives have the information needed to choose a home, which will meet their needs. Prospective residents are assessed prior to moving into the home. A contract of terms and conditions is provided with details about the service they will receive This judgement has been made using available evidence including a visit to this service. EVIDENCE: Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 11 The homes Statement of purpose and Service User’s Guide was available for residents and relatives to view. However the documents are in need of review and update to reflect the change in registered manager. The homes range of fees should be included in the Service User’s Guide. Copies of the documents are available in the reception area of the home. Residents confirmed that they were provided with the appropriate information to assist them with their choice. The inspector was advised that relatives usually visit the home on their behalf - “The home was chosen for me”. Prior to admission, potential residents are assessed by a registered nurse, which is usually the manager to ensure that the home can fully meet their needs. A pre–admission assessment is then completed and this then forms the basis of the residents care plans. We looked at five residents’ pre – admission assessments during the inspection. These showed that the assessments had been completed appropriately. One of the assessments had not been dated at the time of the assessment, the deputy manager was advised to remind all staff to date and sign the assessment. Residents are provided with a statement of terms and conditions on admission to the home. It gives information on what residents can expect to receive for the fee they pay and sets out terms and conditions of occupancy. Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9 and 10 Quality in this outcome area is adequate. The health and personal care that residents receive is based on their individual needs but care plans do not always support this. The home has an efficient medication policy supported by procedures and practise. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five residents care records were reviewed at the time of the inspection. Since the last inspection the home had made significant improvements with the documentation for care plans. However shortfalls with information was noted with the system. Not all nurses were signing and dating their entries on the Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 13 care plan or risk assessments and not all changes to the care documents were being made as necessary. Examples of these were: • A resident had an episode of loose stools and a care plan had not been implemented for this problem. • In another care plan a resident diagnosed with a urinary tract infection had no plan of care developed. • One resident’s care plan recorded the need to assess a wound every three days but this was not being followed. • We observed that there had been a delay in completing risk assessments for a resident admitted on the 15th and the risk assessments were dated the 18th. • Weight loss for one resident had not been identified in the care plan as to how this was being managed. We noted improvements with the care plans. They are now more person centred, and make reference to the resident and or relatives input. A good system for the resident’s social intervention and records are being maintained by the activities organiser. A good range of equipment is available to assist the staff in meeting the health and personal care needs of the residents. Profile beds are provided for all the residents and the nurses confirmed that they have no problems with accessing pressure relieving equipment. A new nurse call system has been fitted to assist the residents in summoning assistance. All staff spoken to demonstrated a good knowledge and understanding of the residents and their care needs. Good interaction was observed between the staff, residents and relatives. Comments from the residents and relatives were most complimentary about the care and the staff. The management of medication was well organised at the time of the inspection. The manager completes a monthly medication audit, which has improved the management of medication. The storage and management of controlled drugs was satisfactory at the time of the visit. Resident’s privacy was seen to be maintained by the staff. Residents and relatives confirmed that all staff respect their privacy and dignity. Questionnaires returned confirmed that the residents were pleased with the care provision. Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 Quality in this outcome area is excellent. Residents have opportunities to be involved and stimulated by a wide range of interesting activities and access the gardens. The dietary needs of the residents are well catered for with a balanced diet and a varied selection of foods. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The activities organiser has further developed her role, and all the residents spoken with are obviously appreciative of her and the individual attention they are now receiving. All residents referred to the activities organiser by her first name, and were most respectful of her position, and how approachable she is. The activities organiser confirmed that she is enjoying her role and has completed an NVQ level 2 qualification in health and social care to help her understand the needs of the residents more. An activities log was developed Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 15 when she commenced in the role and this shows all the activities, outings and contact details for entertainment. A social record is also maintained for each individual residents showing what they have participated in. to assist with the program of activities she holds regular meetings with the residents and the minutes from these are maintained. Two Church services are held each month for the residents. A newsletter is produced on alternate months to update the residents and relatives of forthcoming events. On both days of the inspections the home had entertainment, and all residents appeared to be enjoying this. A link with the local schools has also been developed so that they come and sing for the residents on special occasions. Comments received about the activities included: “Brilliant, residents have a sparkle in their eyes” “The activities are much better” “Activities are good” “stimulation. The activities manager is brilliant, my --------- is much more alert” From the surveys received from the relatives prior to the inspection and comments from visitors on the days of the inspection, all expressed their satisfaction with the home. All said that the staff were friendly and made them feel welcome when they visited. Many relatives were present for the entertainment in the afternoons on the days of the inspection. The meals observed on both days of the inspection appeared appetising, Comments from residents on the days of the inspection included: “Very good, have 2 choices of main meal, about 5 choices of puddings” “Excellent food, good quality, well prepared and well presented” A comment was noted that on occasions the meat could be a little tough. The catering appeared well organised, and the catering staff have devised the menus to ensure that the residents receive their five portions of fruit and vegetables daily. Residents requiring assistance with their meals were being helped in a respectful manner. Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is adequate. The home has a clear policy on how to deal with complaints and the staff and residents were aware of this. Training is planned to assist the staff in recognising any potential signs of abuse so that the residents are protected and have their legal rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection 3 complaints have been reported to CSCI about the home, two of which were referred to the lead agency for safeguarding adults. An investigation is currently in progress with the assistance of other agencies that commission care from the home. Complaints have been in respect of the attitude of staff and the specific care of 2 residents. One of these referrals was unsubstantiated and the other is still being monitored. Also, an anonymous concern was made to the CSCI about the poor moving and handling techniques used by staff in the home. The home has co–operated fully with the Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 17 investigations, and provided details of staff training. The inspector was advised that several staff have left the home since the last inspection and this had improved the atmosphere in the home. The complaints register however does not include all the complaints or provide details of the homes investigation or the outcome of their investigation. The record should also include the timescales from receipt of the complaint, investigation and response times. All staff spoken with during the inspection stated that they would have no hesitation in reporting poor practise, and any potential abuse. The home provides training courses to assist staff in recognising the various types of abuse, and to understand the “whistle blowing” legislation. Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24 and 26 Quality in this outcome area is excellent. Through major investment the environment and grounds are well maintained and provide a comfortable atmosphere for the residents to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the home and grounds was undertaken during the inspection. The home provides large lounges and dining areas, quiet rooms, toilets and bathrooms on each floor. There are twenty-eight single bedrooms with ensuite facilities and ten double bedrooms with en-suite facilities. A lift is available to assist residents to move around the home. Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 19 The gardens continue to be developed so that the residents can use them if they wish, and also provide a pleasant outlook from the home. Resident’s bedrooms were personalised by the resident and in good decorative order throughout. It was recommended that the double bedroom without the fitted curtain divide has one fitted to assist staff delivering personal care. All beds in the home are profile, which assists the staff in meeting the resident’s health and personal care. It was recommended that some of the moving and handling equipment and commodes are reviewed for a more modern version. Residents confirmed that the staff respond quickly when they activate the nurse call system for assistance. The housekeeper was spoken with and stated that it was nice to see the environmental improvements in the home, and how staff work as a team. All areas of the home were observed to be clean and tidy and the management of odours was commended. Comments from the residents and relatives was that the outcome from the laundry was satisfactory -“laundry do a good job”. Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 Quality in this outcome area is good. Staffing levels are proportionate for the number of residents being accommodated. This ensures that their health and personal needs are met. To further safeguard residents the person applying for a job should provide clear details of their continuous employment dates. To ensure that the health care needs of residents are protected all nurses should be clinically up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection the home was accommodating 48 residents. The duty rotas showed that the home was planning staffing levels proportionate for the number and needs of the residents. Residents stated that they felt the staffing levels were good and they never had to wait for long periods when requesting assistance. Staff spoken to also expressed that the staffing levels were good, occasionally they could do with an extra one when staff go off sick Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 21 with no notice. On walking around the home a staff presence was noted in all areas. In addition to the nurses and care staff, the home provides domestic, catering, laundry, maintenance, gardening and administration staff. Comments from the residents, relatives and surveys were complimentary. A comment on a survey rated the staff “excellent” “good” and “poor”. This comment was shared with the deputy manager who confirmed their had been staff issues, but felt this settled when some staff left. The home is working well towards meeting the requirement of having 50 of the care staff with NVQ level 2 certificate in care. A system for monitoring staff training has been further developed since the last inspection. This showed that the majority of staff have completed the mandatory training courses. Some gaps were evident on the chart with food hygiene, infection control and health and safety. The home uses in house trainers to train the staff, it was recommended that this is reviewed given the number of anonymous concerns in respect of moving and handling. The nurses training records showed shortfalls with clinical updates. At the time of the inspection no one was up to date with the management of syringe drivers. All nurses should have regular updates specific to the area in which they practise this will assist in meeting their professional accountability with the Nursing and Midwifery Council (NMC). Three staff files were reviewed during the inspection. The home was following their recruitment procedure and completing the appropriate checks on the applicants. We suggested during the inspection that the home update their application form to provide clear continuous employment history. At present the applicant records only year dates for the start and end of employment without a month it is difficult to assess if there have been any gaps in employment. Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32, 33, 35, 36 and 38 Quality in this outcome area is good. The manager is well supported by the registered person and together they create an open approachable atmosphere. Quality assurance audits are being completed to assist them in listening to the views of the residents. A sufficient process was in place for any money held on behalf of the residents. A staff supervision system is in place for the carers. Good practices are in place for servicing the equipment and systems to assist in protecting the health and safety needs of the residents. This judgement has been made using available evidence including a Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 23 visit to this service. EVIDENCE: The manager was appointed prior to the last inspection. She has set about improving the standards in the home and with the documentation, including the residents care records. She has commenced audits in medication, wound care; infection control and accidents to assist in monitoring the homes performance and also ensure staff are following correct procedures. All staff spoken to during the inspection confirmed that she was supportive and always approachable. We were advised that the manager is in the process of completing the Registered Manager’s Award level 4 qualification. The system for monies held in the home for the residents were checked. It is an individualised system and records all money received, and any outgoings for which a receipt is maintained. Limited staff have access to the residents money and two staff check money going out. The AQAA for the home was received in August 2007 and was appropriately completed. It shows that the home is maintaining the planned improvements stated in the AQAA. The quality assurance was completed in the last 12 months, and the results from this have been reviewed. The home has regular staff and residents meetings. A bi-monthly newsletter is also circulated from the activities organiser to keep everyone up to date with any changes. A staff supervision program is now in place for all the carers and the records from the meeting are maintained on their personnel file. All care staff spoken with confirmed that they were receiving supervision with a senior member of staff and found them useful. The home employs a maintenance operative who has a well organised system for ensuring that the safety checks are completed, all records requested were available and up to date. Herons Park Nursing Home DS0000004116.V357436.R01.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 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 3 X 3 X 3 X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 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 15(1) and (2) Requirement To ensure the residents care needs are being met, the care plans must be developed as soon as possible after admission. The care records should be reviewed and updated when any changes take place. This is to ensure that staff are aware of all aspects of people’s current health, personal and social care needs and that these can be properly met. All complaints made to the home must be fully investigated and a record maintained with details of the actions taken in response. This is to ensure that people’s concerns are explored and resolved and that service improvements are made, if necessary. Appropriate training must be provided for staff to ensure that they have the skills to meet the needs of the residents. The nurses should have regular clinical training to maintain their competencies and skills. DS0000004116.V357436.R01.S.doc Timescale for action 30/04/08 2 OP16 22(3) and 17(2) 30/04/08 3 OP30 18 1 (a) 30/09/08 Herons Park Nursing Home Version 5.2 Page 26 04/04/08 home responded that this standard is now met. 4 OP1 5 (1) (b) To ensure that people have the correct information about the home, the Statement of Purpose must include the range of fees in the Service Users Guide. 04/04/08 home responded that this is now met 30/06/08 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 OP3 OP7 Good Practice Recommendations For professional accountability when nurses make an entry or change to either the pre-admission assessment or care record a date and signature of that nurse should be included. To further safeguard the residents, it is recommended that the application form is updated so as a continuous employment history can be reviewed. To assist in maintaining residents privacy, dividing curtains are recommended for the shared room. 2 3 OP29 OP24 Herons Park Nursing Home DS0000004116.V357436.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Office The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Herons Park Nursing Home DS0000004116.V357436.R01.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. 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