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Inspection on 10/11/09 for Hinckley Park Nursing Home

Also see our care home review for Hinckley Park Nursing Home for more information

This inspection was carried out on 10th November 2009.

CQC found this care home to be providing an Good service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Hinckley Park is currently well managed by an experienced and competent Manager. We found that everyone who lived in home had a care plan that detailed the care and support they needed, and the plans of care had been regularly reviewed. We found the home was clean and pleasant and in the process of being redecorated. It had a bright and friendly atmosphere and staff were observed to interact well with the people who lived there. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.2 Staff were trained to provide a good standard of care. Food was of a satisfactory standard and meals were enjoyed by the people who lived in the home. The home was safe and well maintained.

What has improved since the last inspection?

This was a positive inspection and there were significant improvements to care delivery to the credit of the Manager and her staff. The Requirements & Recommendations following the last inspection had been addressed. Care plans provided the necessary information regarding peoples’ health and personal care needs, and appropriate risk assessments were in place.

What the care home could do better:

To ensure future management stability and ensure quality of care for people who use the service the Registered Provider must appoint a manager who will apply to become the Registered Manager for the service. People who wish to self–medicate must be assessed as being safe and competent to do so to ensure that they receive their medication as prescribed. We recommend that the Statement of Purpose & Service Users’ Guide is available in the reception area at all times. We recommend that care plans are re-organised and simplified to provide greater clarity and reflect a person centered approach to care. We recommend that other agencies and specific community groups are approached for help to provide specific cultural guidance and support for persons from ethnic backgrounds. We recommend that there is written information about advocacy services in the reception area.

Key inspection report CARE HOMES FOR OLDER PEOPLE Hinckley Park Nursing Home 67 London Road Hinckley Leicestershire LE10 1HH Lead Inspector Carole Burgess Key Unannounced Inspection 10th November 2009 09:30 DS0000001911.V378305.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hinckley Park Nursing Home Address 67 London Road Hinckley Leicestershire LE10 1HH 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) 01455 615252 01455 612956 hinckleypark@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Care Centres Limited Manager post vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (40) of places Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following categories of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP Physical Disability - Code PD The maximum number of service users who can be accommodated is: 40 12th March 2009 2. Date of last inspection Brief Description of the Service: Hinckley Park Nursing Home, Southern Cross Healthcare Ltd is a care home with nursing, providing personal care and accommodation for up to forty older persons. Hinckley Park is a purpose built, three-storey property with level entry access. It has two floors provide accommodation for people who use the service. Access to both floors is by passenger lift or stairs. There are thirty single bedrooms, seven with en suite facilities and five double bedrooms, all with en suite facilities. There are additional bathrooms with assisted bathing facilities. There are two communal areas with a television, two dining rooms and a conservatory and a garden to the rear of the building. The third floor accommodates the kitchen, laundry and staff room. The home is located close to the town centre of Hinckley where people have access to shops, the library, the post office and other local amenities. It is easily accessible by private or public transport and there is parking in the grounds. Information about the services provided is available in a Statement of Purpose and Service Users’ Guide. Fees from the placing Local Authorities are arranged and assessed individually. People funded by the local authority may also be asked for a ‘top up’ fee. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.2 Page 5 People who fund their own care are assessed according to their needs and the type of room that they occupy. Hinckley Park Nursing Home DS0000001911.V378305.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 2 stars. This means the people who use this service experience good quality outcomes. ‘We’ as it appears throughout the Inspection Report refers to the ‘Care Quality Commission’ (CQC). Any references to the ‘Commission for Social Care Inspection (CSCI) should be taken as CQC, who now hold the legal responsibilities previously held by the CSCI, as of the 1st April 2009. The inspection process consisted of pre-planning the inspection, which included reviewing the previous Inspection Report and any information we have received since that time. The home had a Key Unannounced Inspection on 12th March 2009. The quality rating at that time was 1 star. This means that people who used the service experienced adequate quality outcomes at that time. The focus of the inspection was based upon the outcomes for people who receive care. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of nursing and care needs and looking at how these were being met by the staff of Hinckley Park. We provided pre-inspection surveys to find out what people thought of the home. At the time of inspection none had been returned to us. What the service does well: Hinckley Park is currently well managed by an experienced and competent Manager. We found that everyone who lived in home had a care plan that detailed the care and support they needed, and the plans of care had been regularly reviewed. We found the home was clean and pleasant and in the process of being redecorated. It had a bright and friendly atmosphere and staff were observed to interact well with the people who lived there. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.2 Page 7 Staff were trained to provide a good standard of care. Food was of a satisfactory standard and meals were enjoyed by the people who lived in the home. The home was safe and well maintained. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.2 Page 8 order line – 0870 240 7535. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 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 Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People (or their representative) who may be considering living at Hinckley Park can access the information they require to enable them to make an informed choice about if the home is the right one for them. EVIDENCE: We wanted to look at the information provided to people who lived at Hinckley Park to find out whether it was detailed and answered all of their questions. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 Page 11 The home had produced two documents which provide the relevant information - the Statement of Purpose and Service Users’ Guide - both documents provide information about the services provided, staffing arrangements, the home’s philosophy of care, and how it supports people who lived there. These are usually kept in the reception but were not there on the day of inspection. We found that a copy of the Service Users’ Guide was provided in peoples bedrooms. There was also a generic, company Statement of Purpose on audio cassette if this was required. We wanted to find out how the Manager of the home can be confident that the service it provides can meet the needs of people, especially those with nursing care needs, before they move into the home. People whose care was funded through health or social services had an assessment carried out by the authority funding that persons care which was kept in the person’s care file. The Manager, who is a Registered Nurse, said that she also completes a preassessment of peoples’ needs to ensure that they can be met once they move into the home. We looked at the records of four people living in the home, which included people who were receiving both residential and nursing care. We found that assessments were satisfactory, and contained information to determine whether the needs of the person could be met, these assessments were used to develop a provisional care plan, which was in place when the person moved into the home. The home does not provide intermediate care. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans were satisfactory and reflected the health and personal care needs of people who live at Hinckley Park. EVIDENCE: We wanted to find out how the health and personal care needs of people living at Hinckley Park were met. We spoke with people living in the home along with a two visiting relatives, and observed the care and support provided by staff; we also looked at the care plans and records of four people, three who required nursing care and one person who required residential care. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 Page 13 We found care plans to be satisfactory regarding peoples’ health and personal care needs. However, the views of the individual should be expanded upon to include a person’s wishes as to how they would prefer to spend their day, for example what time they wished to get up and go to bed, where they would like to eat their meals and how frequently they wished to bathe. The Manager told us that the organisation, of which Hinckley is part, is reviewing the format of documentation, including care plans, which would enable peoples’ preferences to be recorded in greater detail and would support a Person Centred Care approach to care. Care plans were in place for each identified healthcare need, and had been reviewed and updated as required. We found that risk assessments were undertaken and where assessments identified a risk, a care plan had been developed that provided information to ensure that peoples’ care needs were identified and met. However, in some instances the hand writing was poor which made it difficult to read the care plan, whilst others were very clear and well written. Overall we found care plans complex and information difficult to locate which could affect the quality of care that nurses and care staff provide. Medication management was checked and found to be satisfactory. All medication was administered by a trained Nurse. We looked at the medication and medication records of the people who were ‘case tracked’ and found them to be in good order. It was noted that there had been three medication errors earlier this year but this had been addressed, and most of the Nurses had received updated training with Boots the Chemist and there had been no other recorded medication errors since that time. One person was self medicating their inhalers. Although there was care plan that stated he was doing so there was no indication that a formal risk assessment had been undertaken to ensure that he was competent to administer his medication and ensure that he was receiving his medication safely as prescribed. Observation during the inspection showed that staff had a good awareness of how to protect peoples privacy and dignity. Staff spoke to people living at the home in a friendly and helpful way. We observed that people who remained in bed due their health care needs, had the call bell placed next to them so that they could call for assistance. We spoke with two visitors and six people who live in the home. They said that they were happy living in the home, and that staff were kind and supportive. They said that they were able to see a doctor when they wanted to and that they felt well cared for. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The daily routine and appropriate activities at Hinckley Park means that people are given the opportunity to enjoy leisure and recreational activities that meet their assessed mental, physical and social care needs. EVIDENCE: We wanted to find out how people spend their day, and how the staff working at the home support people to make decisions and stay in contact with relatives and friends, we did this by observing people throughout the day, talking with people at the home, and by looking at the care plans and records of four people who live in the home. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 Page 15 There was an activities co-ordinator who organises a range of activities throughout the week. We saw the weekly plan of activities and observed people taking part in organised activities throughout the day of the visit although people could choose to spend quite time in their rooms if this was preferred. A programme of activities was arranged throughout the week with photographs of recent events on the activities board. On the day of the visit people listened to CD’s organised by a resident and other people enjoyed watching and singing-a-long to a film – ‘The Sound of Music’. We were told that two Shetland ponies had been brought in to visit the previous day and that people were able to pat and stroke them, which people said they enjoyed. There were no people with any specific religious needs but we were told that that there was a Church of England service held in the home every week and that all were welcome. We found social care plans, in most cases, were brief and provided little insight into people as individuals e.g. by providing detailed information about family, friends, past lives, work, hobbies, likes and dislikes etc. We noted that one person had very specific language and cultural needs which had not been explored. We discussed this with the person’s family and the Manager. It was evident that a person centred plan of care would enable nurses and carers to provide a more individualised approach that would address individual lifestyle expectations and cultural preferences. We spoke with people who lived in the home and asked them about the meals provided. People said that the meals were nice and that there was always a choice. Peoples’ care plans had nutritional assessment and weight records as required. The kitchen had details of people’s specific needs such as soft or diabetic diets to ensure that these were catered for. Those people who required assistance were given this in a discreet and unhurried manner. People spoke with said that there was enough to do in the way of activities but two people said that they would like more opportunities to go out when the weather was better. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Hinckley Park (and/or their Relatives) are able to express their concerns, and have access to the home’s complaints procedure. EVIDENCE: We wanted to find out how the staff at Hinckley Park promoted the safety and welfare of people living at the home. The home had a complaints policy and procedure which was incorporated into the Statement of Purpose and Service Users’ Guide. A copy of the Service Users’ Guide, which included the complaints policy, was provided for people in their bedroom. We had not received any complaints from the general public about the home but the local authority was aware of and dealt with a number of concerns which have now been addressed and concluded. The local authority and the service have made us aware of a concern that has been returned to the Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 Page 17 provider by the local authority to investigate under their safeguarding procedure, the outcome of which will be available to us in due course. The home had a copy of the local multi-agency policies & procedures on the protection of vulnerable adults. Most of the staff had had ‘Safeguarding Vulnerable Adults’ training within the last twelve months in line with local authority guidelines, and were aware of ‘whistleblowing’ procedures, to ensure that they know how to protect people who live in the home. However, some staff were a little unclear regarding the role of individual agencies in safeguarding procedures. The Manager said that this will be addressed at the next staff meeting. We noted that there was no information on advocacy available. We recommend that there is written information about advocacy services in the reception area for people who use the service, or there relatives, who may require independent help or advice. People spoken with said that they knew how to complain if they needed to and who to speak with if they had any concerns. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Hinckley Park provides a clean, safe and well-maintained environment. EVIDENCE: The home is large with accommodation on the ground and first floors; with the kitchen and laundry on the second floor. The service providers had redecorated some areas of the home and had an ongoing programme of refurbishment. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 Page 19 The areas of the home that were seen were decorated and furnished to a satisfactory standard and were clean and tidy. Internal doors to stairways had been fitted with key codes to ensure the safety of people who have dementia and may wander. A passenger lift provides access to all floors. The home had adaptations such as grab rails, and sufficient additional toilets and adapted bathing facilities. We noted that two chairs in the reception area looked stained and did not give a good initial impression. This was discussed with the Manager as a general point. She hopes that they will be replaced once the decorating in the reception area is completed. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home receive training and are sufficient in number to meet the nursing and care needs of the people who currently live at Hinckley Park. EVIDENCE: We wanted to find out whether there were sufficient staff on duty to meet the care needs of the people, many of whom required nursing care, living at Hinckley Park on the day of the inspection visit. There was a Registered Nurse on duty on each floor throughout the day, and one Registered Nurse at night. The nurses are supported by three care staff per floor on the early shift and five care staff across the ground and first floors on the late shift, and two care staff at night. The Manager worked in a supervisory capacity and there were additional administrative, domestic, Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 Page 21 maintenance and kitchen staff which ensured that nurses and care staff were free to provide care for the people who lived in the home. We checked the home’s recruitment policy and procedure. There was a robust staff recruitment and selection process. We looked at four staff files. They were neat and well maintained and contained all of the necessary preemployment checks, along with confirmation of the persons identity, and included a recorded interview, two written references and a Criminal Record Bureau (CRB) disclosure, obtained prior to staff commencing work at the home, to ensure that staff were ‘fit’ to work with vulnerable people. The nurses’ files contained current Personal Identity Number (PIN) to show that they were registered with the Nursing & Midwifery Council (NMC) as proof of nurse’s ‘fitness to practice’ and ensured the safety of the people who lived in the home. The Manager had a training matrix which identified training that had been provided, and shortfalls in training which needed addressing. Staff underwent a recorded induction and were provided with annual mandatory training in key areas such as Fire Safety, Food Hygiene, Moving & Handling, Health & Safety and Safeguarding Vulnerable Adults. Information supplied by the Manager during our visit told us that more than 50 of care staff had attained a National Vocational Qualification (NVQ) in Care. This and the mandatory training ensured that staff were able to provide safe care for the people who lived at Hinckley Park. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Manager, who has been in post since June 2009 ensures that the home is run in the best interests of people who receive care. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 Page 23 EVIDENCE: The Home has been without a Registered Manager for approximately two years. This has resulted in instability in the quality of care resulting in the home being rated 0 Star Poor in August 2008 & 1 Star Adequate in March 2009. The current Manager, a Registered Nurse, had worked in care since 1987, and had worked at the home since June this year. The Manager had a clear understanding of the home, and was working hard to improve the service. She stated her intention to apply for Registration with CQC the following week (week ending 22nd November 2009). We spoke with the Manager to check the management of people’s money to ensure that their financial interests were safeguarded. Written records and receipts were maintained for small amounts but bank accounts are managed by relatives or the person’s representative where this is required. Quality Assurance Audits on various aspects of care such as medication, falls etc are completed and actioned and Questionnaires had been provided for relatives and people who lived at the home bi-annually to establish their views about the care and the service they received. These were sent to for collation and returned to the Registered Manager to action. The Manager had implemented a programme of staff supervision to ensure that staff were supported and had there trainng needs identified. Information provided by the Manager in the AQAA prior to our visit detailed the regular maintenance of equipment and systems in the home, including health and electrical systems along with fire fighting equipment and systems. We looked at training records and found that staff had received training linked with health and safety; training included fire safety, food hygiene, COSHH and Health and Safety to ensure that the staff and people who lived in the home worked and lived in a safe environment. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 Page 25 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 OP31 Regulation 8 (1) (2) 9 (1) Requirement The Registered Provider must appoint a manager who will apply to become the Registered Manager for the service. Timescale for action 31/12/09 2. OP9 13 To ensure future management stability and ensure quality of care for people who use the service. People who wish to self-medicate 20/11/09 must be assessed as being safe and competent to do so. To ensure that they receive their medication as prescribed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations We recommend that the Statement of Purpose & Service DS0000001911.V378305.R01.S.doc Version 5.3 Page 26 Hinckley Park Nursing Home 2. 3. OP8 OP13 4 OP17 Users’ Guide is available in the reception area at all times. We recommend that care plans are re-organised and simplified to provide greater clarity and reflect a person centered approach to care. We recommend that other agencies and specific community groups are approached for help to provide specific cultural guidance and support for persons from ethnic backgrounds. We recommend that there is written information about advocacy services in the reception area. Hinckley Park Nursing Home DS0000001911.V378305.R01.S.doc Version 5.3 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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