Inspection on 23/11/05 for Herons Park Nursing Home

This inspection was carried out on 23rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 23/05/07

Herons Park Nursing Home 12/05/06

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 23rd November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 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.V261920.R01.S.doc Version 5.0 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.V261920.R01.S.doc Version 5.0 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. 25th August 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. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over three and a half hours from 9am until 12.30pm. The inspector was assisted by Sister Julia Matthews. She also spoke to three residents, and four members of staff. A partial tour of the building and a range of documents were seen. The focus of the inspection was on the recommendations that had been made following the previous inspection, and standards concerned with protection and rights, the premises, infection control, staffing and safety. A service questionnaire was completed by the home prior to this inspection and returned to the Commission for Social Care Inspection. The manager was asked to distribute other questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but proves useful in assessing the various views that are held. Fifteen responses were received. What the service does well: What has improved since the last inspection? Since the last inspection five bedrooms have been redecorated and new carpets laid. A new bath hoist has been provided. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 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.V261920.R01.S.doc Version 5.0 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.V261920.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not inspected during this inspection. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 9 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): EVIDENCE: These standards were not inspected in depth during this inspection. However the records of one person with a pressure sore were assessed. It was observed that there was a detailed wound care plan but not a detailed plan for pressure area care. The care plan for a person prescribed antidepressants lacked detailed guidance instructing staff of the value of personal contact with people who do not verbally communicate. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 10 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): EVIDENCE: These standards were not assessed in full. However one resident was distressed that she was not receiving help to wash and dress each day until late in the morning. At 10.30am she was still waiting for assistance. The activities organiser was working effectively with the residents upstairs and it was pleasing to see the previously silent people respond to her. She worked on weekdays. One questionnaire respondent said that it would be nice to have something to do at weekends and one person said that the activities provided were not suitable. This is a matter of individual taste and interest that emphasises the need to know and be able to respond to the preferences of individual residents. It was observed that an activities programme for the week was displayed and the notice board advertised a clothes party, a raffle and a visit from a choir. The activities organiser said that she would be attending a training course in January next year. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 11 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, 17, 18 Information is available to advise people how to raise their concerns. Residents are at risk because the home has not applied for checks to be undertaken and acceptable responses received from the CRB and POVA register for some newly appointed staff commence their duties. Training is not provided therefore staff may not be able to recognise and respond to situations of concern relating to abuse. EVIDENCE: The complaint record contained no entries since the last inspection. A procedure was available and a copy was displayed. Only one questionnaire indicated that the respondent did not know who to raise concerns with. The residents’ legal rights were protected and they were registered to take part in elections if they wished. Everyone had a named care supporter and a named trained nurse supporter. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 12 Policies and procedures are available to protect vulnerable people. However the records of one recently appointed member of staff contained a CRB disclosure that had been obtained by a previous employer. This is not acceptable. CRB disclosures are not portable. A new CRB and POVA check must be made for each recruit. Staff had not received training in the recognition and protection of residents from abuse. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 13 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 The residents live in a clean well maintained home that meets their needs. The risks of cross infection are reduced by the facilities and training provided. EVIDENCE: A short tour of the home was conducted. It was clean, well maintained and comfortably furnished. Liquid soap, disposable towels and hand cleaning equipment were appropriately provided. The laundry was small but well equipped. It could be readily cleaned but there was an accumulation of dust behind the machines. A cleaning routine needed to be established to address this. Staff had received in-house training in infection control, correct hand washing techniques and MRSA. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 14 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, 29, 30 There are insufficient staff on duty each morning to meet the needs of the residents in a timely manner. Staff receive training to enable them to provide the care the residents need but there is not an overall picture that enables training needs to be identified and prioritised. EVIDENCE: A requirement was made following the previous inspection that: “Staffing numbers and skill mix must be appropriate to meet the assessed needs of the service users, the size, layout and purpose of the home at all times. Additional staff must be on duty at peak times of activity during the day.” During this inspection the staff on both floors were still helping residents to wash and dress after 10.30am. It was apparent that this was not through the choice of residents or the lack of effort of staff. Forty-four residents needed help with their personal care and this took time and patience. More staff needed to be employed at peak times. Residents’ care plans should indicate if they have a preference or health need for rising and retiring at a particular time and staff should be available as necessary to respond. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 15 Four of the trained staff, that had been working as care assistants while they undertook adaptation training and obtained their qualification ‘PIN’ number, were now looking for alternative employment as trained nurses. This would place additional strain on the remaining staff team that they do not have the flexibility and numbers to cope with. The records of two recently appointed staff were assessed and were found to be complete with the exception of one CRB check that had been undertaken by the person’s previous employer. CRB and POVA checks are not portable and must be renewed for each new employer and change of care role. It was not known if all staff had received a copy of the GSCC code of Conduct and Practice or if the new staff had commenced their induction training. Not all training records were readily available. In-house training sessions led by the trained nurses frequently took place in the home and a register was maintained of attendees. Recently training had been given in the management of diabetes, tissue viability and heart failure. A training analysis was not available so it was not possible to obtain an overall picture of the training situation. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 16 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): 38 Training, servicing and monitoring systems are in place to ensure the home is a safe place. EVIDENCE: The nursing sister assisting the inspector was unsure of the location of the quality assurance system in use. Therefore it will be assessed during a future inspection. Only the manager, or in his absence the deputy manager, had access to the residents personal monies held in safekeeping. Access was not possible during this inspection as the deputy manager was off sick. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 17 Training was undertaken in health and safety matters but it was not known which of the staff were trained first aiders. Therefore it was not possible to be sure there was a first aider on duty at all times. The service pre inspection questionnaire and records indicated that equipment was being appropriately service and monitored. The Fire Risk Assessment for the home was drawn up in 2001. Usually it would be advisable to review this document but the inspector was aware that new legislation is expected in January and it was therefore thought advisable to wait and address any necessary changes at one time. Fire safety training and drills were undertaken but it was not possible to identify who had not received training. A monitoring chart would be useful for this purpose. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 19 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 Care plans must be available to advise and guide staff in respect of all care needs (e.g. in respect of care of pressure areas and residents who have limited communication and are being treated for depression, as identified in the plan sampled during this inspection). Staffing numbers and skill mix must be appropriate to meet the assessed needs and wishes of the service users, the size, layout and purpose of the home at all times. Additional staff must be on duty at peak times of activity during the day. A minimum of five care staff and one trained nurse must be on duty on each floor each morning. A cleaning routine should be established for behind the laundry equipment. Timescale for action 01/01/06 2 OP27OP14 18 01/01/06 3 OP26 13 01/01/06 Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 20 4 OP29 Standards 89 All new staff must not commence 23/11/05 their duties until the home has applied for and received acceptable CRB and POVA clearance. 5 OP30 12, 18 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 of abuse and protection of vulnerable adults. A qualified First Aider (four day first aid at work course) should be on duty at all times. 01/01/06 6 OP38OP30 12, 18 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP29 OP38 OP38 Good Practice Recommendations All staff should receive a copy of the GSCC Code of Conduct and Practice when they are appointed. A monitoring tool should be used to ensure staff receive the correct updates of fire safety training and attendance at drills. The fire risk assessment for the home should be reviewed with any changes to the legislation that are made in the new year. Herons Nursing Home, The DS0000004116.V261920.R01.S.doc Version 5.0 Page 21 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. 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