Inspection on 23/05/07 for Herons Park Nursing Home

This inspection was carried out on 23rd May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Herons Park Nursing Home 14/02/08

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 Yvonne South Key Unannounced Inspection 23rd May 2007 08:45 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.V335653.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.V335653.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 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.royalbay.co.uk Regency Old Homes Plc Mrs Sandra Packwood (Registered manager designate) 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.V335653.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. 5th February 2007 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 designate 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. On 27.04.06 the manager stated that the fees were between £447 and £480. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that incorporated information received by the Commission for Social Care Inspection since the previous key inspection, which took place on 12.05.07, a random inspection which took place on 05.02.07 and the information obtained during fieldwork on 23.05.07. The fieldwork took place over ten hours, during which the inspector spoke to three residents and three staff. Documents were assessed and a partial tour of the premises was also undertaken. The registered manager designate gave assistance. Prior to the fieldwork the home was asked by the CSCI to complete and return a pre-inspection questionnaire and to distribute questionnaires to the residents and health care professionals seeking their opinions of the service. To date one response has been received from a resident and four from health care professionals. The focus of this inspection was on the key National Minimum Standards and requirements and recommendations that arose out of the previous inspections. In November 2006 the shares of the registered provider company, Regency Old Homes Plc, were bought out by Royal Bay Care Home Ltd. It is the new shareholders stated intention that they will be changing the name of the company to Royal Bay Care Homes Ltd in due course. The name of the home has already been changed from The Herons Nursing Home to Herons Park Nursing Home. In March 2006 the registered manager Mr Sam Naujeer resigned his post and the current manager Mrs Sandra Packwood was appointed. An application has been made to the Commission for Social care Inspection for her to be registered as the manager of the home. Throughout this report Mrs Sandra Packwood is referred to as ‘the new manager’ or ‘the manager’. What the service does well: Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 6 The home offers a warm welcome to everyone who visits. The environment is clean, attractive and well maintained. There are nurses and care staff available at all times to attend to the needs of the people who live in the home and to give them support in their lives. A wide range of stimulation and activities are provided for those who wish to join in. Support is regularly given by the local vicar and minister for those who wish to attend religious services. 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. What has improved since the last inspection? What they could do better: Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 7 The records systems in the home need to be simplified and put in good order. Residents’ care records are cumbersome so at times it is difficult to locate and update the information and guidance required. This puts residents at risk of not receiving the care they need. Residents, or with their consent their representatives should be encouraged and supported to be involved in discussions and agreements regarding care plans and reviews. Information should be obtained regarding each persons’ wishes in relation to end of life care and death. This is a sensitive subject but if the information is not available then the individual’s wishes cannot be met. Staff training needs to be formalised and well managed. A training matrix is being compiled so that training needs are identified and prioritised. The new manager has decided that all staff will receive up to date training in all core care subjects including those relating to health and safety. This has already started and the risks to people who live and work in the home have been reduced. 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.V335653.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, (This home does not offer an intermediate service. Therefore standard 6 was not assessed.) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some information is available to assist people to make a decision regarding their care and accommodation. However the information contained in the Statement of Purpose and Service Users’ Guide is being up dated so there is no access to detailed information regarding the service. The needs of all prospective residents are assessed prior to admission so that places are only offered if the home can provide the care needed. EVIDENCE: Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 10 Work was in progress to update the Statement of Purpose and Service Users’ Guide to reflect the recent changes relating to the registered providers, responsible individual and management of the home. Despite the lack of these documents the home had got an up to date brochure that contained information regarding the home. These were readily available for prospective residents and their representatives who were also given opportunities to look around the home and speak to the manager and administrative director. Only one questionnaire was returned to the Commission for Social Care Inspection by a resident. This stated that the respondent had received all necessary information to help him make a decision regarding his future home and care and he considered that the ‘new owners’ were keeping the residents well informed about proposed changes. An assessment of care records demonstrated that someone from the home visited prospective residents prior to admission and assessed their needs. Places were only offered if it was considered that the home could provide the care needed. The assessment document that was in use was a ‘tick box’ design, which provided limited information and lacked individuality. This weakness had been identified during the random inspection carried out on 05.02.07 when the previous manager was still in post. The current manager agreed that the format needed to be improved and she was working on the care record system with the new deputy manager to achieve this. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Changes in medication management ensure that residents receive their prescribed medication safely. The inconsistencies in care planning provide flawed information and guidance for staff and place the residents at risk of not receiving the care they need. EVIDENCE: During the random inspection undertaken in February this year it was identified that the weaknesses in planning to meet current/changing needs of residents, and involving residents and/or their representatives, continued. On going weaknesses were also identified relating to the safe management of medication. Since then the previous manager had left and the newly appointed manager had been in post for five weeks before this key inspection was conducted. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 12 During the fieldwork for this key inspection the care records of three residents were assessed. Two people had care needs relating to dementia illnesses and the third person had nursing needs. The quality of the care planning continued to be variable. Although some care plans were detailed and informative others were not dated and signed, some care plans had not been developed or updated, some risk assessments had not been carried out. The record system in use was cumbersome and in some areas repetitive. There was little evidence that residents, or with their consent, their representatives, had had any involvement in the care planning and review process. The new manager was aware of the need to improve the documentation so that appropriate care plans were always available to instruct staff and provide them with the correct information and guidance to enable them to care for the residents. As previously mentioned the manager designate had said that it was intended to implement a new records system as soon as possible. The weaknesses in medication management had been addressed very well. The home had changed to the Boots Modular Dosage system and Boots had undertaken the training of all the registered nurses. A full training pack had also been made available for use with any newly appointed nurses in the future. It was observed that storage was acceptable and the documentation was well maintained. A homely remedies policy and agreement had been accepted by all local surgeries that had patients in the home. The questionnaires that were returned to the Commission for Social Care Inspection indicated that the local GPs were reserving judgement concerning the change of management. However the questions were given predominately positive answers. The resident who responded said that his GP was very helpful and, with input from the home, his medication had been successfully changed and physiotherapy arranged following a fall. A resident in the home told the inspector that the care was fundamentally good and GPs were responsive. The relative of a resident who had recently died was very appreciative of the end of life care and support her father and family members had received. Another relative said that the health care was good, as was the communication between the home and herself. Staff were observed to relate to residents in an acceptable manner. Doors were knocked on before entry, residents could make and receive phone calls in private and mail was delivered to the addressee unopened. Telephone points were available in all bedrooms, although currently only one resident had a private phone. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 13 Bedroom doors were fitted with locks that met the criteria agreed with the Fire Authority and the manager said that keys would be offered to each resident on admission unless a risk assessment indicated that it would not be acceptable. Herons Park Nursing Home DS0000004116.V335653.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): 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 opportunities to be involved and stimulated by a wide range of interesting activities and access the gardens. EVIDENCE: A new activities organiser had been appointed and was working thirty hours each week. The pre-inspection questionnaire gave examples of the activities that were now available for those residents who wished to participate. These included exercise and music, hand massages, clothes parties and church services. A photographic record contained wonderful photographs of residents enjoying Easter bonnet competitions, visits from ‘pat the dog’, a ‘reptile encounter’ with a Savannah Monitor Lizard and participation in church services held by different church representatives during which one of the residents played the keyboard for the hymns. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 15 It was apparent from the photographs that all residents, including those with dementia illnesses, had been involved and had been interested and stimulated. Plans had commenced to improve access to and around the garden and there was an intention to build a conservatory. One resident said that although he had little interest in the increased variety of activities provided he did appreciate the prospect of enjoying the garden. A small sunny courtyard garden with a fountain and raised flowerbeds was already completed and a resident was observed sitting in the sun enjoying his book and fresh air. Current residents belonged to four different Christian faiths and services were held in the home for those who wished to attend. The manager said that there were no communication difficulties with residents as a consequence of nationality or sensory loss. However some people had communication losses as a result of mental frailty. The home now had two new chefs and the residents told the inspector that the meals were excellent. The samples of menus demonstrated that a varied and nutritional choice was offered. A member of staff was observed discussing the choices with the residents and giving the support they needed to make a decision. However later it was observed that a resident who needed to be fed was assisted by a member of staff who did not demonstrate the necessary skill. The manager was made aware. Herons Park Nursing Home DS0000004116.V335653.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): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Concerns, complaints and allegations are responded to appropriately so that standards are improved and residents are protected. The staff recruitment process and training provision has been improved so that residents are protected. EVIDENCE: The Commission for Social Care Inspection received an allegation in September 2006, prior to the change of shareholders and responsible individual, regarding the home. The allegations were referred to the Adult Protection team for investigation and no evidence was found to support them. The complaint record in the home held the details of a recently received complaint that had regarded a moving and handling issue. This had been investigated by the new manager and all staff had renewed their training in moving and handling. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 17 Two relatives confirmed that they had raised concerns regarding the attitude of some staff, that some staff were unobservant, lacked flexibility and had not reacted to residents’ needs. These matters had been drawn to the attention of the new manager who was described as responsive. Relatives also stated that some staff were excellent. These included some of the carers and nurses, the activities lady and the housekeeper. Recently extensive recruitment of staff had taken place. On appointment the new manager identified that references and checks by the Criminal Records Bureau (CRB) and of the Protection of Vulnerable Adults (PoVA) List had not always been carried out and results received before new staff commenced work. This had been addressed and she confirmed that an acceptable recruitment procedure now always used. The records of three staff were assessed by the inspector and were acceptable. Some staff had undertaken training relating to the identification and response to abuse and those who spoke to the inspector confirmed that they would respond to any concerns they might have. The manager said that it was her intention that all staff would receive an up date of all mandatory training including the protection of vulnerable people. Herons Park Nursing Home DS0000004116.V335653.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, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents are benefiting from the major improvements in the home and grounds. The environment is comfortable and there is suitable equipment to meet their needs. EVIDENCE: A partial tour of the home was undertaken by the inspector. It was observed that there were communal large lounges with dining areas, quiet rooms, toilets, bathrooms on each floor, and a shower room on the ground floor. There were twenty-eight single bedrooms with ensuite facilities and ten double bedrooms with ensuite facilities. A shaft lift and hand rails assist movement in the home. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 19 In November 2006 the new shareholders commenced work to improve the fabric of the home and grounds. A new sign had been erected outside that displayed the new name and ownership of the home. Inside the entrance, the reception area and corridors had been attractively redecorated. Lighting had been improved throughout the home and bedrooms had been redecorated, refurbished and refurnished. These looked warm, comfortable and welcoming. Fifty new ‘profile’ beds had been purchased. Furniture had been rearranged in some communal areas to good effect and attractively framed pictures had been hung. Alcoves in corridors had been converted to provide much needed storage and the medication trolleys had been stored out of sight in secure rooms. This had further improved the ambiance of the home. The manager said that there were plans to replace the adapted baths and modernise the bathrooms, with one being converted to a wet room. A new call bell system had been installed that was less intrusive than the previous wired system, and easier for the staff to identify where their help was needed. In the grounds a sheltered courtyard had been developed with raised flowerbeds, a water feature and seating. Paths had been laid in the main garden to enable easier access for people who had difficulties with mobility. When completed this area would be secure and private. It was observed that antibacterial hand gel was placed at the entrance and around the home with encouragement for its use. Liquid soap, disposable towels, clinical waste bins and personal protective equipment were available in all necessary areas. The manager confirmed that she was arranging for all staff to receive updated training in infection control. The laundry facilities had been improved and suitable machines were available. Sluices were old fashioned and in need of improvement. The manager agreed and confirmed that these were included in the improvement plans. Herons Park Nursing Home DS0000004116.V335653.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): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is sufficient staff employed to meet the needs of the residents. Residents generally receive good care however due to the lack of staff training they cannot be confident of a continuous high standard of care from everyone. EVIDENCE: During the random inspection that took place on 05.02.07 the inspector was told that staffing had been increased in all areas and skills. The pre-inspection questionnaire indicated that there were now nineteen first level nurses, forty-eight care staff and twenty-three ancillary staff employed. Most of the staff were white British. However the staff team also included three people from India and one person from South Africa. The manager said that these people had no communication difficulties in the home but on occasions there were problems when using the telephone. The manager was unaware of any religious or cultural needs that required support in the home. Male and female staff were employed so those residents who preferred to receive personal care from someone of the same sex, could be accommodated. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 21 An assessment of three sets of staff records demonstrated that some checks by the Criminal Records Bureau (CRB) and of the Protection of Vulnerable Adults (PoVA) list had not been completed or the results received before new staff had commenced their duties. However the new manager became aware of this on appointment and had addressed it. She confirmed that an acceptable recruitment procedure was now always fully implemented. The manager, two nurses and a secretary had resigned since the last inspection. A new deputy had been appointed and was working closely with the new manager to address the unmet requirements placed on the previous manager. All staff had been provided with new uniforms and will also receive new contracts and terms and conditions of employment. Following the random inspection a requirement had been made that appropriate training must be provided for staff. Work on the training analyses and programme had not been completed and the records indicated that all staff had not received training in the protection of vulnerable adults as was required. The new manager said that she was in the process of recording individual training profiles for all staff and would use this to develop a full training matrix. Past records had been uninformative and therefore a fresh start had been necessary. All mandatory training was being updated and by 15th June 2007 all staff would have received moving and handling and fire safety training. The pre-inspection questionnaire stated that seventeen care staff had National Vocational Qualifications (NVQ) to level 2 or above. This equated to approximately 35 , which was below the 50 required by National Minimum Standards. However nine staff had commenced work on NVQ courses. The inspector interviewed three staff. They considered that the changes in the home had been positive and the new management seemed very good and approachable. There were some concerns that all staff were not receiving full information regarding changes as they commenced shifts at different times. One person said that the improvements to staffing levels were appreciated, the senior nurses were superb and responded well to problems and standards. Everyone was clear of the action they should take in an emergency, on receipt of a complaint and if they observed or suspected abuse of any resident. Residents and relatives stated in the questionnaire responses and personally that some areas of person care could be improved and some staff needed a greater awareness of the implications of short-term memory loss. Other comments made included • ‘Most staff are very good.’ Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 22 • • • • ‘The activities lady is very good and willing. She does good work and gets people involved.’ ‘The housekeeper is excellent. She has a real rapport with the residents.’ ‘Some staff are very good while others are unobservant and neglectful’. ‘Night staff are a particular worry’. The relative of a deceased resident was very appreciative of the high standard of care he had received and the support that the home had given to his family. The manager was aware of the concerns that had been raised and said that she was addressing them. She was pleased that the high quality of some staff had been appreciated. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new management team are improving and developing the service for the benefit of the residents. Health and safety is well addressed in all aspects except training. Moving and handling and fire safety training has been updated so that people are safer. The manager is addressing other areas of health and safety training for the well being of all in the home. EVIDENCE: Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 24 Following the random inspection the registered manager tendered his resignation and a new manager and deputy were appointed. At the time of this key inspection the new manager had been in post for five weeks. The questionnaire responses from GPs indicated that they were reserving judgement regarding the changes to the home. One person stated; ‘I am uncertain that the home has settled fully with new staff yet. Previous care and communication has been good’. Other doctors stated; ‘Outstanding level of care. They cope well with multiple complex problems’. ‘Home has just changed management. There has been a period of great upheaval. There seems to be an effort to improve medication issuing and the environment. We wait to see how things will develop’. The new manager had submitted her application to the Commission for Social Care Inspection for registration. She had enrolled on the course to achieve the Registered Managers’ Award and already had twenty years of experience in the care of the elderly, teaching and assessment as well as an extensive range of training in care /nursing related subjects. The manager said that since her appointment she had undertaken an assessment of the home and care and was developing and implementing an action plan that prioritised and improved all aspects of the service. The ‘Mulberry House’ quality assurance system was in use. This included full risk assessments and health and safety. Audits were being undertaken and the results were being used to inform action plans for improvement and development. The management of residents’ personal monies was unchanged and in the past has been acceptable. It was not assessed during this inspection. The premises and equipment were well maintained and appropriately serviced. The manager said that there were plans to replace some of the older pieces of equipment. Much of the catering equipment in the main kitchen had already been replaced and increased. Health and safety systems and equipment were well addressed through monitoring and servicing. Good records were maintained. However the lack of training was a serious concern. Staff were observed pushing residents in wheelchairs without the use of footplates. This puts the resident at risk. They may tip out of the wheelchair or injury their feet and legs. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 25 Requirements were made following the random inspection regarding the supervision of staff and fire safety training. The manager said that fire training had been booked and all staff were scheduled to be updated in June 2007. It was known that insufficient staff had first aid qualifications and this was being included in the training plan as was all other mandatory subjects relating to health and safety. The manager and deputy had worked out a supervision programme and were about to implement it. Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 26 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 2 X 3 X X N/A 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X 2 Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement In consultation with the resident, or with their consent their representative, care plans must be written that describe how the resident’s needs in respect of their health and welfare will be met. Care plans must be kept under review and updated or discontinued as necessary. This requirement was not met in full within the timescale set (30.06.06) under the previous management. Therefore it has been repeated. Timescale for action 01/09/07 2 OP30 18 Appropriate training must be provided for staff. This requirement had not been met in full within the timescale set (01.11.06) under the previous management and has therefore been repeated. 01/12/07 Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 28 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 Good Practice Recommendations The pre-admission document should be redesigned to include all topics listed in standard 3.3 and enable individual details to be recorded effectively. Information must be sought and recorded to enable resident’s end of life wishes to be carried out. 1. OP11 Herons Park Nursing Home DS0000004116.V335653.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Worcester Area 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.V335653.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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