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Inspection on 19/08/08 for Hinckley Park Nursing Home

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

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

The service provides a comfortable, homely environment for the people who use the service to relax in. The garden is well equipped with a seating area, there are large beds of scented flowers. The staff interactions observed were very respectful and dignifying to all people who use the service. People confirmed that the staff were kind and caring. One person commented, "I like it here, the staff are kind and caring". Assessments are detailed and reflect the diversity and preferences of the person using the service. The menus are nutritional and a range of snacks items and drinks are available throughout the day. The service has a number of management systems in place to audit and check the quality of the service being provided.

What has improved since the last inspection?

Recruitment is on going and the manager commented they are attempting to recruit more bank staff to cover any planned or unplanned short falls. A manager is now in post and is working through the short falls that have been identified at this and the last inspection. Some training has occurred for the staff.

What the care home could do better:

A number of areas have been identified as requiring development. Care plans must be reflective of the needs of the person receiving the care and detail sufficient information in order for the care to be provided. The Health and welfare records were not up to date or completed in full, thus not ensuring the health and well being of all people using the service are supported and protected. Medication must be managed effectively.Staff must be trained appropriately to ensure that the skill mix of the team is suitable to meet the needs of the people using the service. Training must be provided in Safeguarding of Vulnerable Adults, nutrition, Health and Safety, fire safety and infection control to ensure that people who use the service are protected and that staff are suitably trained to meet individual needs. A schedule of training is required in order to ensure that staff have a planned training plan in place to meet the needs of their individual roles. Staff must receive periodic supervision and appraisal to ensure that they are supported and competent to do their role. Suitable recruitment pre employment checks must occur to ensure that the people who work in the service are suitable and that the people who use the service are safe and protected. Safeguarding referrals and notifications must be made on all occasions where there is any risk; to ensure the safety of the people that use the service is maintained. The statement of Purpose must contain the fee ranges for the people who use the service and be reviewed to ensure the information they have is accurate and up to date. Records in the service must be stored safely, maintained, up to date and accurate to ensure that the care and support needs of the people using the service are met at all times.

CARE HOMES FOR OLDER PEOPLE Hinckley Park Nursing Home 67 London Road Hinckley Leicestershire LE10 1HH Lead Inspector Louise Bushell Unannounced Inspection 19th August 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hinckley Park Nursing Home DS0000001911.V370258.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. Hinckley Park Nursing Home DS0000001911.V370258.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.V370258.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 3rd August 2007 2. Date of last inspection Brief Description of the Service: Hinckley Park Nursing Home is a care home with nursing facilities providing personal care and accommodation for up to forty older persons. Southern Cross Healthcare Ltd owns the home. Hinckley Park is a purpose built, three storey property with level entry access. It has two floors for residents use. Access to both floors is by use of a passenger lift or stairs. There is a third floor, which accommodates the kitchen, laundry and staff room. There are thirty single bedrooms, seven with en suite facilities, and five double bedrooms, all with en suite facilities and 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 home is located close to the town centre of Hinckley where residents 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. Information about the services provided are available in a statement of purpose and service user guide. These documents were under review at the time of the inspection. The following fees were provided by the Acting Manager as being current at the time of inspection on 19th August 2008: Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 5 Local Authorities who are funding residents are charged at a set rate of £346 per week plus any additional nursing contribution. The nursing contribution varies according to the assessed needs. Currently the nursing contribution is £103.80. Residents funded by the local authority will also be asked for a ‘top up’ fee, which varies between £10 and £50 according to their ability to pay. Privately funded residents are charged according to the room that they occupy which are: Single room with en-suite toilet and washbasin -£585 per week plus any nursing contribution. Single room with no en-suite - £560 per week plus any nursing contribution. Double shared room - £450 per week plus any nursing contribution. Double room used by one person - £700 per week plus any nursing contribution. The fees include personal care and where applicable nursing care, accommodation, meals and laundry. Chiropody (£7) and hairdressing services (£5-50 - £20-00) can be arranged and are charged separately. Hinckley Park Nursing Home DS0000001911.V370258.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 0 star. This means the people who use this service experience poor quality outcomes. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of the information held by the Commission for Social Care Inspection as part of the pre-inspection planning and an unannounced inspection visit to the service. The pre-inspection planning was carried out over the period of a day and involved reviewing the service history, which details all contact with the home including notifications of events reported by the home, telephone calls, letters, and details of any complaints and concerns received. The report from the last key inspection was reviewed and the findings taken into account when planning this inspection. The inspection visit was unannounced inspection and covered the morning, afternoon and evening of a weekday. The inspection was carried out by ‘case tracking’ which involves selecting people who use the service and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices, interactions with staff and their general well being. The inspector also spoke with other people who were not part of the case tracking process. An annual quality assurance assessment (AQAA) submitted by the manager was received and reviewed as part of the inspection process. Some views from people who use the service and relatives were obtained during the inspection and have been taken into account as part of the inspection. As part of the information gathering process the Commission for Social Care Inspection, forward questionnaires for distribution to a selection of people who use the service and their relatives. This information has been taken into account as part of the inspection. Shared areas and a sample of individuals bedrooms were viewed during the inspection and observations were made of the daily routines. A sample of records including staff files was viewed to check the adequacy of the recruitment process in protecting people. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 7 Verbal feedback on the inspection findings was given to the Manager during the inspection. What the service does well: What has improved since the last inspection? What they could do better: A number of areas have been identified as requiring development. Care plans must be reflective of the needs of the person receiving the care and detail sufficient information in order for the care to be provided. The Health and welfare records were not up to date or completed in full, thus not ensuring the health and well being of all people using the service are supported and protected. Medication must be managed effectively. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 8 Staff must be trained appropriately to ensure that the skill mix of the team is suitable to meet the needs of the people using the service. Training must be provided in Safeguarding of Vulnerable Adults, nutrition, Health and Safety, fire safety and infection control to ensure that people who use the service are protected and that staff are suitably trained to meet individual needs. A schedule of training is required in order to ensure that staff have a planned training plan in place to meet the needs of their individual roles. Staff must receive periodic supervision and appraisal to ensure that they are supported and competent to do their role. Suitable recruitment pre employment checks must occur to ensure that the people who work in the service are suitable and that the people who use the service are safe and protected. Safeguarding referrals and notifications must be made on all occasions where there is any risk; to ensure the safety of the people that use the service is maintained. The statement of Purpose must contain the fee ranges for the people who use the service and be reviewed to ensure the information they have is accurate and up to date. Records in the service must be stored safely, maintained, up to date and accurate to ensure that the care and support needs of the people using the service are met at all times. 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. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5. Standard 6 is not applicable, as intermediate care is not provided. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process is comprehensive and provides assurances that the needs of people admitted to the home can be met. EVIDENCE: The service has developed a statement of purpose, which sets out the aims and objectives that the person can expect to receive. This includes a guide, which provides basic information about the service and the specialist care that is available. The guide details what the prospective people using the service can expect and gives an account of the specialist services provided, quality of the accommodation, qualifications and experience of staff and how to make a complaint. The statement of purpose did not contain the information relating to the fee ranges for people using the service. The statement of purpose did not show that it had been recently reviewed and that the information contained within was relevant and up to date. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 11 All people who use the service are given a copy of the guide. One person stated that “I like it here, the staff are kind and caring”. A person using the service stated, “My husband came to look around the place to see if I would be ok here”. Admissions are not made to the service until a full needs assessment has been undertaken. A senior person always completes the assessment prior to admission to the service. A number of pre assessments were seen. The service then compiles a pre admission draft care plan for the person. The assessment explored areas of diversity including preferences, religious and cultural needs, involvement from family, partners and advocates, race and disability and sexuality. It was evident that the service strives to seek the information and assessment through care management arrangements, prior to admission. The service has the capacity to support people who use the service and respond to diverse needs that may have been identified during the assessment process. The information gathered from the AQAA states “All relatives / residents are encouraged to visit the home prior to a pre-admission assessment, and are welcome to join us for a meal, social activity, or to stay at the home on a short term basis in order to make an informed choice. Rehabilitative care is a focus at Hinckley Park and we have a specialist contract bed with the health authority to offer rehabilitation and short-term assessment services for people leaving hospital who might wish to have additional support prior to them returning to their own home”. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service and relatives are happy with the healthcare provided however the lack of up to date, detailed care plans and records has the potential to put residents at risk of their needs not being met and serious health and safety issues for the staff. EVIDENCE: A total of two care plans were case tracked fully. It was evidenced that the care plans did not consistently detail the care and support that is to be provided to the people using the service and the documentation relating the activity actually being provided was not completed in full. Examples of this were seen with regards to care plans regarding fluid and food intake, turning charts and personal hygiene charts. Additional examples were evidenced through the care plan not detailing the manual handling needs of one person using the service. Risk assessments had not been completed for the manual handling tasks required. Staff and the person using the service confirmed that Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 13 manual handling operations did occur. Additional examples were evidenced through the Malnutrition Universal Screening Tool (MUST), this had not completed and there was no evidence of a nutritional care plan being in place even though the person was at risk of malnutrition as identified in the initial assessment. The Evidence was gathered in relation to continuing non compliance, following a requirement being made at the last inspection regarding care planning. Enforcement action is being considered. Staff were observed to respect the privacy and dignity of all people. An example of good practice was observed by two staff members positively engaging with an individual through a hoisting procedure. The service listens and responds to individual choices and decisions about who delivers their personal care. The care plan also details personal preferences, this included food types, night-time preferences, activities, religion, personal appearance, personal time and how the person would like to be addressed. People are supported and helped to be independent and can take responsibility for their personal care needs as detailed in their care plan. People who use the service have access to healthcare and remedial services. The health care needs of residents unable to leave the service are managed by visits from local health care services. The AQAA states “Staff have received training on Liverpool Care Pathway and the Gold Standards Framework and have improved their understanding, knowledge and approach to end stage care. Improved care planning that reflects the full health and social care needs of an individual and through person centred planning, ensures residents and relatives views are included”. Review of the responses in surveys received from a sample of people who use the service and relatives identifies that the majority are happy with the nursing care that they receive. Views on support for personal care vary and include “I think the staff are very caring and do a good job”. “We are always short of staff for the clients needs, taking staff from other departments to help. There is a knock on effect to complete our workload in our time and causing work related stress to all staff” The service has an efficient medication policy. Medication records are maintained on Medication Administration Records (MAR). It was evidenced that there were some gaps in the administration of medication. Three medications were observed to have not been booked in correctly as they did not contain double signatures from staff booking them in. One medicine stock balance was incorrect and it was not able to be established whether or not the medication had been administered and taken or not administered. An immediate requirement was issued. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 14 The medication trolley was bolted appropriately to a wall, and records were being maintained of the room temperature and fridge temperatures. Protocols were not in place for action to take if the temperature exceeds the recommended range for storage. The manager completes monthly medication audits and records were seen. The manager stated that the staff have completed and passed an appropriate medication course. An assessment has been carried out to ensure each member of staff is competent to handle record and administer medication properly. The majority of care plans reviewed contained suitable and sensitive plans and arrangements for the management of end of life. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Visitors are encouraged and welcomed into the home and the people are happy with the quality of food provided. However the level of stimulation and activities is limited. EVIDENCE: A number of people who use the service provided varied comments about the level of activities provided. One person stated that “we used to play lots of bingo and we now don’t do a great deal”. Another person stated “we don’t really do much, just sit here really”. The manager stated that there is now outside entertainer one a month and notices were observed on the notice board. At the time of the inspection there was no activities organiser working due to sickness and no alternative activities had been organised. The activities coordinator had only been in post approximately three weeks. At the beginning of the inspection, discussion occurred with the manager regarding compliance with requirements made at the last inspection. The manager stated that she did not feel that the requirement regarding activities had been fully met due to Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 16 the only recent employment of the activities coordinator. Records for activity completion / involvement were observed and not sufficiently completed to determine that activities had improved since that last inspection. The Evidence was gathered in relation to continuing non compliance, following a requirement being made at the last inspection regarding activity levels. Enforcement action is being considered. The AQAA has identified that the service aims to complete the following over the next twelve months “Training for the activity co-ordinator and to achieve a recognised qualification to practice. To enable the activities co-ordinator to attend support forums within the county, to share good practice and generate additional ideas for developing the activities programme. To increase the social fund by organising various fund raising events and to use the money specifically to for trips out. To ensure all staff are aware of the role of activity co-ordinator and the benefits of having activities within the home and to participate and support residents, particularly with activities of daily living. To start developing life story books for each resident”. Discussion with a number of people who use the service confirmed that there are flexible visiting arrangements and staff were heard to acknowledge and welcome visitors. One person commented “ my son comes every Thursday for an hour”, whilst another person commented “ my visitors can come when they like and when they can”. People who are mobile are able to access all parts of the home and one person confirmed that they can access the garden as and when they wish. However for those who need assistance with movement and handling the control over their lives can be limited and dependent on the availability of staff. Many of the people who use the service commented that the food was varied and appetising. They confirmed that they do get a chocie of meals being provided. Observations of the lunch time meal confirmed that this was freshly cooked and looked and smelt appetising. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 17 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. The and had and service has a robust complaints procedure in place, good staff awareness attitude towards safeguarding issues. Reporting procedure and notification not been completed to ensure that the people who use the service are safe protected at all times. EVIDENCE: The service has an open culture that allows people who use the service to express their views and concerns in a safe and understanding environment. People who use the service have commented that they are happy with the service provided; feel safe and well cared for. A number of comments received determined that people who use the service and relatives and friends are aware of what to do if they have any concerns. One person using the service commented “we are quite happy here, no complaints”. The AQAA states “We listen to any concerns that are raised and act on them appropriately within a short timescale, as per company policy and procedures. The complainant is responded to within 28 days, following a full investigation of their complaint. The complaints procedure is on display in reception. We have a whistle blowing policy for staff and implement local protocols to ensure staff are totally comfortable with reporting anything they Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 18 consider might put residents, or the home at risk. POVA (Protection of Vulnerable Adults) and abuse training is provided for all staff and updates provided each year.”. The service has a complaints procedure that is clearly written and easy to understand. It is available in a number of formats such as different languages on request. The complaints procedure is supplied to everyone living at the service and is displayed in a number of areas within the service. There is record of all complaints and compliments made and received. The service has received one written complaints in the last year. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. Staff commented that they have received training in safeguarding and felt confident in reporting any issues as they occurred. The service provides in house training in safeguarding of Vulnerable Adults through people that have attended a trained trainer’s course. The service had identified a number of people who have been discharged from hospital with pressure sores. These have not been reported through the notifications procedure nor had they been reported following the local area multi agency procedures to ensure protection from abuse. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the service enables the people who use the service to live safely in a well-maintained homely environment. EVIDENCE: The service provides a physical environment that is appropriate to the specific needs of the people who live there. The environment provides a homely feel with specialist aids and equipment to meet needs as required. The service is a pleasant, safe place to live; the bedrooms and communal room provide a personal and homely feel. The decoration throughout the building is on a rolling programme of redecorating. The AQAA determines that the service has improved over the last twelve moths by the completion of all outstanding maintenance tasks. Monthly home and validation audits are completed and Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 20 show that the home is maintained to a high level. The layout of the building enables people to move freely where they reside, with several different seating areas throughout to encourage socialising or enabling the person to have privacy. The AQAA has identified that the following improvements to the service are planned to take place in the next twelve months; “Further re-decoration of bedrooms, bathrooms and communal areas”. The people who use the service appear to like the environment, were relaxed, comfortable, and settled. The garden areas have flowers and tables and chairs, promoting independence and a homely feel. The people who use the service are encouraged to personalise their bedrooms. All the home’s fixtures and fittings meet the needs of individuals and can be changed if their needs change. The dining rooms are laid out to encourage communal dining with a calm relaxed atmosphere. The environment promotes the privacy, dignity and autonomy of residents. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. The home has an infection control policy. The service is clean, well lit and smells fresh. One comment received from a general practitioner stated that the service was “generally a caring home”. There was restricted access to high-risk areas such as the main kitchen and the laundry areas to reduce the risk of cross infection. The Laundry room has recently been fitted with an air conditioning unit. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 21 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 poor. This judgement has been made using available evidence including a visit to this service. Some staff were trained; however a number of staff did not have Safeguarding of vulnerable adults, infection control, nutrition, health and safety and fire safety training, staff recruitment checks did not ensure the protection safety and well being of the people who use the service. EVIDENCE: Feedback from the people who use the service shows that they have confidence in the staff that care for them. Staff Rotas were seen and displayed adequate numbers of staff on duty to meet the needs of the people using the service. The manager is in addition to daily staffing numbers; this enables staffing levels to be maintained for the safety of all. One staff member commented, “I feel we work well as a team. My colleagues and I support each other well. There is good communication between us”. There is a good recruitment policy that clearly defines the process to be followed. However the procedure followed was not adequate to ensure sound recruitment procedures had been followed. Three staff files were audited and did not contain all the information to ensure that the people who use the service are adequately protected and in safe hands at all times. One staff Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 22 member was working in the service without any references or a criminal records bureau check (CRB). A further member of staff had been employed for a number of months and did not also have suitable references held on their file. This person was also working with only a POVA 1st clearance. The administrator stated that she was in the process of sorting through all of the files and showed an action plan of the short falls regarding information required to be held on the files. An immediate requirement was issued regarding compliance with recruitment for the protection and safety of the people using the service. Once recruited staff receive induction and training. The programme is then signed at the end of each stage. The AQAA determined that “All staff receive a 3 day induction programme and this is signed off as they complete each area. Continuous recruitment of staff on to the bank ensures we have adequate staff and the skill mix required for the residents needs. On going staff training and support. Management continually audits the home any issues raised from this are dealt with.” The training matrix showed that a number of training needs were required. This included health and safety, nutrition, infection control, safeguarding of vulunerable adults, fire safety andfood hygiene. There was not a plan in place for training for the forth coming months. The manager stated that a number courses had been arranged however no evidence was provided to show this. Staff confirmed that staff meetings occur and a number of comments received on the staff surveys determined that the staff feel involved and updated. The mix of staff is suitable to meet the cultural needs and mix of people that use the service. Staff generally reported that they felt supported in their roles and that they were able to discuss issues with a member of the senior team if required. The manager commented that they are recruiting bank staff to fill the planed and unplanned short falls within the team to bring more consistency to the service. Hinckley Park Nursing Home DS0000001911.V370258.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, 33, 35, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People benefit from living in a well-managed service but some improvements are needed in relation to supervision, record keeping, in order to ensure that peoples well being is maintained and that they are protected and safe. EVIDENCE: The Manager has been in post since April 2008. The manager is yet to become registered with the Commission for Social Care Inspection. The Manager displayed a clear understanding of the key principles and focus of the service, based on organisational values and priorities. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 24 The AQAA determines that a total of 85 of staff either have or are working towards their National Vocational Qualification (NVQ) in Care. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. The service has good policies and procedures, which are corporately and internally reviewed and updated, in line with current practice. The AQAA determines tat these have been reviewed. The manager ensures that staff follow the policies and procedures of the home. This includes the management of finances within the service, where systems were directly observed to be transparent and open, with detailed records being maintained at all times. Staff meetings take place regularly and minutes of the meetings are available. There are clear internal quality assurance procedures which are completed by the manager on a monthly basis. The operations manager visits the service to complete the Regulation 26 visits. The last records seen were for May 2008. The manager has not received any formal supervision since she has been in post. Quality assurance surveys are also distributed to the people who use the service. This was discussed in full with the manager. The findings from the surveys are not feed back to the people who have completed them with an action plan of works identified through the surveying. The home works to a clear health and safety policy. The service provides a range of policies and guidance to underpin good practice. In house training is scheduled for safeguarding. Staff showed a working knowledge of action to take in such an event. Internal training is being provided by people trained as trainers. The internal training provided by the trainers is not certified other than from their individual training qualifications. Discussions occurred with the manager regarding notifications to the Commission for Social Care Inspection and referrals using the local area multi agency protection policy for those people who are admitted to the service from another place with pressure sores. Care plan records on the first floor were seen to be on display in an open nurses station and not ensuring that peoples confidentiality is being respected and dignified at all times. All health and safety records are up to date. A recent environmental health inspection occurred and a number of recommendations were made. These actions have already been sourced and works are underway. In general the report finalised that “No follow up is required and very good standards”. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 25 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 3 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 2 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 2 2 Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12 (1) (a, b), 15 Requirement Care plans must be reflective of residents’ current health and welfare needs and sufficiently detailed to guide staff in meeting needs. (This requirement with the original timescale of compliance for 30/10/07 has not been met. Enforcement action is now being considered.) Timescale for action 19/08/08 2. OP12 16 (2) (m, Arrangements must be made for 19/08/08 n) residents to receive activities and stimulation taking account of their varying needs and choices. (This requirement with the original timescale of compliance for 30/09/07 has not been met. Enforcement action is now being considered.) 18 (1) (c) (i) Arrangement must be made for staff to receive training in safeguarding of vulnerable adults, infection control, nutrition, health and safety and fire safety to ensure that people are in safe hands at all times. DS0000001911.V370258.R01.S.doc 3 OP28 20/12/08 Hinckley Park Nursing Home Version 5.2 Page 27 4 OP8 15 (1) & (2) 5 OP30 18 (1) 6 OP9 13 (2) Health and welfare records must 10/10/08 be accurate and completed in full to ensure the health and well being of all people using the service is supported and protected. A schedule of planned training 30/09/08 must be in place to ensure that all staff receive mandatory training as required. Suitable arrangements must be 19/08/08 in place for the safe accurate administration of all medicines to all people who use the service to ensure their safety and wellbeing at all times. (An Immediate Requirement was issued during the inspection. Compliance was achieved within the time scales set). 7 OP29 19 (1) & (4) (c) Schedule 2 19/08/08 Suitable and adequate pre employment checks must occur to ensure that the people who use the service are kept safe and protected at all times. (An Immediate Requirement was issued during the inspection. Compliance was achieved within the time scales set). 8 OP18 12 (1) (a) 37 9 OP36 12 (1( (a) & 18 (2) 17 (1) (a) 10 OP37 Safeguarding referrals and 19/10/08 notifications must be made on all occasions where there is any risk; to ensure the safety of the people that use the service is maintained. Staff must receive periodic 30/10/08 supervision and appraisal to ensure that they are supported and competent to do their role. Records in the service must be 15/10/08 stored safely, maintained, up to DS0000001911.V370258.R01.S.doc Version 5.2 Page 28 Hinckley Park Nursing Home 11 OP38 12 (1) (a) 12 OP1 4 (1) date and accurate to ensure that the care and support needs of the people using the service are met at all times. The health, well being and safety 15/10/08 of the people who use the service must be maintained at all times to ensure they are protected. The Statement of Purpose must 30/10/08 contain the fee ranges for the people who use the service and be reviewed to ensure the information they have is accurate and up to date. 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 OP9 OP38 OP27 Good Practice Recommendations A protocol should be implemented to provide guidance for staff and actions to take if stored medication exceeds the recommended temperature. The service should feedback the results and an action plan following the recent quality assurance questionnaires for the people that use the service. Staff should receive local authority certified training for the Safeguarding of Vulnerable Adults. Hinckley Park Nursing Home DS0000001911.V370258.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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