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Inspection on 19/10/06 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 19th October 2006.

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.

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

There was a pleasant atmosphere in the home and staff on duty presented as keen to meet the needs of residents. There is a thorough assessment and admission process in place which identifies residents` needs prior to them being admitted to the home and reviews their needs in the early days following admission. Visiting times are flexible and visitors were seen to come and go freely throughout the day of the inspection. While activities appear to be limited three outings had been arranged for residents` during the summer. Residents` spoken with were happy with the meals provided. Lunch on the day of the inspection appeared appetising and residents` had a choice of meal. The cook was trying new recipes with added nutritional content to tempt residents prescribed fortified food products to reduce the risk of weight loss. The home was clean and comfortably furnished and a staff member was seen to be carrying out a thorough clean of a resident`s bedroom.

What has improved since the last inspection?

A copy of the current guidelines for adult protection had been obtained as recommended at the last inspection.

What the care home could do better:

Care plans, which are documents to guide staff in meeting residents needs were not up to date and did not include all their needs. There was also no guidance for staff as to how best to manage the behaviour of a resident with dementia. While it was positive that outings for resident have been arranged more could be done to provide stimulating activities for residents on a day to day basis. Staff advised that at present activities often consist of music or television. There is a formal complaints procedure in place, however concerns raised on a day to day basis do not appear to be investigated or acted on. For example details of concern about the practice of a staff member were found on a resident`s care file during the inspection with no evidence of any investigation. Failure to investigate such concerns puts residents` and staff in a vulnerable position.Comments about staffing levels and the impact this has on the care of residents was raised by residents/relatives with an example given of delays in receiving assistance with toileting. Additional staff training is needed to ensure that staff have received the necessary training to meet the specific needs of residents. Records to demonstrate a thorough recruitment process were not in place and indicated that references had not been obtained for one member of staff and criminal record bureau clearances although applied for did not appear to have been received. Hinckley Park Nursing Home would benefit from a period of management stability and the implementation of a comprehensive quality assurance programme, which focuses on reviewing and improving outcomes for residents.

CARE HOMES FOR OLDER PEOPLE Hinckley Park Nursing Home 67 London Road Hinckley Leicestershire LE10 1HH Lead Inspector Mrs Kathy Jones Unannounced Inspection 19th October 2006 10:00 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 Hinckley Park Nursing Home DS0000001911.V314730.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.V314730.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 Southern Cross Care Centres Limited Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (3), Physical disability of places over 65 years of age (40), Terminally ill (1), Terminally ill over 65 years of age (1) Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No one falling within category PD may be admitted into the home where there are 3 persons of category PD already accommodated in the home No person under 55 years of age who falls within category PD or TI may be admitted into the home No one falling within category TI or TI(E) may be admitted into the home when there is 1 person of TI or TI(E) already accommodated within the home 28th July 2005 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 an attractive, recently refurbished 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 parking. The following fees were provided as being current at the time of submission of the pre-inspection questionnaire on 3 July 2006: • Fees range between £331 and £540 dependent on assessed need. (Note- In addition any additional allowances awarded as a result of a nursing assessment are added to the fee.) The fees include personal care and where applicable nursing care, accommodation, meals and laundry. Chiropody (£6) and hairdressing services (£2-50 - £7-50) can be arranged and are charged separately. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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 existing evidence, pre-inspection planning, an unannounced inspection visit to the home and drawing together all of the evidence gathered. The pre-inspection planning was carried out over the period of half 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 and any complaints received. A pre-inspection questionnaire submitted by the operations manager, four comment cards from residents/relatives and three comment cards from health professionals were received and taken into account. The report of the last inspection carried out on the 28 July 2006 was also reviewed. The information gathered assisted with planning the particular areas to be inspected during the visit. The unannounced inspection visit covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’, which involves selecting samples of residents’ records and tracking their care and experiences. The selection of records and discussions were guided by comments received from relatives and the previous inspection report. Observations of the homes routines and care provided were made and the inspector spoke with residents’, staff and visitors. The management of residents’ medication was checked. A sample of staff files were also reviewed to check the adequacy of the recruitment procedures. Communal areas and a sample of residents’ bedrooms were viewed and observations were made of residents’ general well being, daily routines and interactions between staff and residents. Verbal feedback was given to the manager on the inspection findings throughout the inspection. A new manager had just taken up post the week of the inspection. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Care plans, which are documents to guide staff in meeting residents needs were not up to date and did not include all their needs. There was also no guidance for staff as to how best to manage the behaviour of a resident with dementia. While it was positive that outings for resident have been arranged more could be done to provide stimulating activities for residents on a day to day basis. Staff advised that at present activities often consist of music or television. There is a formal complaints procedure in place, however concerns raised on a day to day basis do not appear to be investigated or acted on. For example details of concern about the practice of a staff member were found on a resident’s care file during the inspection with no evidence of any investigation. Failure to investigate such concerns puts residents’ and staff in a vulnerable position. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 7 Comments about staffing levels and the impact this has on the care of residents was raised by residents/relatives with an example given of delays in receiving assistance with toileting. Additional staff training is needed to ensure that staff have received the necessary training to meet the specific needs of residents. Records to demonstrate a thorough recruitment process were not in place and indicated that references had not been obtained for one member of staff and criminal record bureau clearances although applied for did not appear to have been received. Hinckley Park Nursing Home would benefit from a period of management stability and the implementation of a comprehensive quality assurance programme, which focuses on reviewing and improving outcomes for residents. 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. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, std 6 is not applicable as intermediate care is not provided. Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The admission process establishes the homes ability to meet the needs of people admitted to the home prior to admission. EVIDENCE: Questionnaires received from two relatives and two residents said they have contracts however; one relative felt there was a lack of clarity with the fee structure. The inspector was informed that the range of fees is as detailed in this report under brief description of services and that the actual fee will be dependent on the assessed needs of the prospective resident. The admission procedure is explained within the statement of purpose, which includes information about the services provided. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 10 Records indicated that there is a thorough assessment and admission process which identifies residents’ needs prior to them being admitted to the home and reviews the needs in the early days following admission. Information about prospective residents needs is also gathered from other sources in the form of an assessment carried out by other bodies such as the placing authority. However review of a resident’s file showed that a relative had provided information about their needs and preferences, during the assessment process. While this information was on file it had not been incorporated into the care plan. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. The lack of up to date care plans which provide staff with clear guidance as to the actions required to meet residents’ needs puts residents’ at risk of their needs not being met. EVIDENCE: Comments received in four questionnaires from relatives and residents state that residents usually get the care and support that they need. One said that they could wait half an hour or more for a response from the call bell. Another said that it could be fifteen minutes to half an hour from asking to go to the toilet and getting there. As the comments relate to staffing issues this has been dealt with in the staffing section of this report. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 12 Care plans are in place, which are intended to be tools to guide staff in providing care appropriate to the needs and preferences of residents’. Review of a sample of residents’ plans identified that the information contained within them was not always reflective of their current needs or sufficiently detailed. Care files for two residents who had nutritional assessments, which identified them, as being at very high risk had no care plans in place to identify how their nutritional needs were to be met. A care plan for a third resident identified as being at nutritional risk was in place however this was very general and did not include details of the residents preferred diet as described by a staff member. Risk assessments were in place to identify residents at risk of pressure ulcers and a sample check indicated that these are reviewed regularly. However although there is an evaluation process for care plans this was not consistently carried out and it was not possible from the records to identify the current skin condition of a resident who had been treated for pressure ulcers. A care plan for the management of aggression was in place for a resident who was recorded to have been involved in two incidents which had the potential for serious consequences for other residents. The plan contained general statements such as “monitor effects of medication”, “remove any agitant”. The care plan did not provide staff with any useful guidance or strategies for managing the behaviours or indicate any exploration of possible triggers or causes of the resident’s distress. Questionnaires were received from two general practitioner surgeries. Two contained all positive comments however the third stated that staff do not demonstrate a clear understanding of residents’ needs, do not always communicate clearly with them and that appropriate decisions are not always made when they can no longer manage the care needs. A sample check of residents’ records show that various healthcare services are accessed on behalf of residents such as general practitioner, optician, dentist and discussion with a staff member identified that some referrals were being made to the dietician. However there was no evidence of a request being made for referral to a community psychiatric nurse in respect of a resident displaying aggressive behaviour. A check of a sample of residents’ medication was carried out which identified a discrepancy of two tablets when checked against the record. However the systems in place for the management of medication are generally good. The manager advised that there is an audit system for medication, which will be implemented and carried out monthly, which will identify any discrepancies. The inspector was also informed that there has been a recent change of pharmacy supplying the medication and that they are going to provide staff with additional training. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 13 Care staff and domestic staff were seen and heard to treat residents’ with respect throughout the inspection. Residents spoken to during the inspection had no concerns about the way they are treated. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. 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 all the available evidence including a visit to the service Visiting arrangements are flexible and the standard of meals is good however increased opportunities for interaction and stimulation would improve the daily lives of residents’. EVIDENCE: Information about activities in the home was provided with the pre-inspection documentation. The activities for July, August and September consisted of a raffle, three minibus outings, and two sing a long sessions and a church service. Discussions with staff identified that the daily activities for residents’ mainly consist of music or television and that there is little in the way of stimulating activities on a day to day basis. One resident spoken with was being nursed in bed and was quite happy with her own company, visitors and the television. Another resident spoken with was accepting of the fact that staff had little in the way of time to spend with them. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 15 Information about residents’ religious needs is gathered during the assessment process. One recently admitted resident’s records showed that her religion was catholic, however there was no information about how she was going to be supported with her religious needs. Visiting arrangements are flexible and visitors were seen to be able to visit in private and to be able to come and go at varying times of the day. Residents’ spoken with were happy with the meals provided. Lunch on the day of the inspection appeared appetising and residents’ were seen to have a choice of meal. The cook advised that she had received some new recipes to assist with increasing the nutritional content of meals for particular residents prescribed fortified products. The use of the recipes also provided residents with more variety in their diet. Discussion with staff during the inspection identified that the importance of liaison between nursing and care staff and the cook about individual dietary needs is understood. The manager advised that she intends to develop these communication links to improve outcomes for residents. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. 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 all the available evidence including a visit to the service. Practice in relation to the management of complaints and concerns and failure to investigate puts residents at risk. EVIDENCE: Questionnaires received from four relatives/residents identify that they are aware of how to make a complaint. The complaints record in the home showed that there had been no recent complaints, however information received from a relative identified that verbal complaints have been made. While there is a formal complaints procedure in place, concerns raised on a day to day basis do not appear to be investigated or acted on. For example details of concern about the practice of a staff member were found on a resident’s care file during the inspection with no evidence of any investigation. Failure to investigate such concerns puts residents’ and staff in a vulnerable position. The Commission for Social Care Inspection have referred one complaint to the responsible individual to investigate since the last inspection. The complaint was about standards of care and staff attitude and is yet to be investigated. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 17 None of the staff spoken with had received any training in protection of vulnerable adults, however were aware of their responsibilities in reporting any concerns that put residents at risk. A pre-inspection questionnaire identifies that protection of vulnerable adults training is being planned. The manager acknowledged the importance of reviewing the practice in relation to the management of complaints and the confidentiality of records in order to safeguard residents who have raised concerns. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The premises were clean and comfortable providing residents’ with a pleasant place to live. EVIDENCE: Communal areas of the home and a sample of residents’ bedrooms were seen during the inspection. Residents are accommodated on the ground and first floor of the home with communal lounges and dining room on each floor. All areas were clean and comfortably furnished. Discussions with staff confirmed that there is a planned cleaning programme in place and staff were observed carrying out a thorough clean of a resident’s bedroom. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 19 Several residents’ are nursed in bed and the inspector noted while talking to one of the resident’s that care had been taken to place family photographs where they could be easily seen. Drinks and the call bell were also placed within easy reach. The inspector was informed that a new patio area had been built since the last inspection, providing residents with a pleasant area to sit. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29,30 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. Staffing arrangements do not evidence that they are based on residents’ needs or that residents’ are properly safeguarded. EVIDENCE: From comments received in four questionnaires from residents’/relatives, two stated that staff were sometimes available when needed, while two said they usually were. One commented “There does seem to be a shortage of staff especially at weekends”. A relative identified that residents are sometimes waiting between 15 and 30 minutes for assistance to the toilet causing residents distress if not able to get there in time. Comments were supported by discussions with staff and a relative, which identified that staffing levels were particularly low in the afternoons. For example on the day of the inspection there were seventeen residents on the first floor, fourteen who needed the assistance of two carers. In addition to the high levels of physical care needs, the inspector noted from a sample check of care files that one resident required close observation and monitoring by staff as they had displayed behaviours on at least two occasions, which put other residents at risk. It had been planned for there to be a registered nurse and two carers in the afternoon on that floor, however one of the staff did not turn up for work and was unable to be replaced at short notice. A requirement has been made to review the staffing levels in relation to the needs of residents. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 21 The pre-inspection questionnaire identifies that seven registered nurses are employed but that only one of the fifteen care staff have achieved a National Vocational Qualification or equivalent in care. It is considered good practice to have at least fifty percent of staff with such a qualification as it provides staff with a basic understanding of care practices. Staff spoken with during the inspection, were keen to achieve the qualification and were waiting for this to be arranged. Records were difficult to locate during the inspection however discussions with staff indicated that staff training had ‘slipped’. The preinspection questionnaire did however identify that a range of staff training is planned based on residents needs which includes diabetic management, dementia, pressure area care, nutrition, and falls prevention. The new manager advised that one of her first tasks would be to update the staff training matrix in order to clearly identify the shortfalls in staff training. A sample check of staff files was made to check the adequacy of the recruitment process. Records were poorly organised and it was not possible to confirm a thorough recruitment process. For example references and a satisfactory criminal record bureau clearance could not be found on one member of staff’s file. Criminal record bureau clearances could not be found for two other recently employed staff. While checks had been made against the protection of vulnerable adults register, no arrangements were in place to protect residents. It was agreed with the new manager that arrangements would be made to ensure that the three members of staff would not work unsupervised with residents until it could be confirmed if a criminal record bureau clearance had been received. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. Consistent management and leadership are needed to improve standards of care and protection for residents’. EVIDENCE: There is no registered manager in post and Hinckley Park Nursing Home has been without a manager. A new manager has been appointed and had just started work in the week of the inspection. The findings of the inspection, discussions with staff and relatives identify the need for consistent management and leadership. For example, management of complaints and staff recruitment and training. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 23 Quality assurance documents were not available at the time of the inspection and it was not possible to identify a comprehensive quality assurance programme that was improving outcomes for residents. However the Commission for Social Care Inspection have received copies of reports confirming that operations managers from Southern Cross have carried out unannounced visits. The most recent report received is of a visit carried out in July 2006. This highlights that some deficits in quality have been identified with management changes and that staff were working towards improvement. The new manager was aware of some of the organisations quality assurance tools and was intending to implement audits in various areas, for example, medication. A small amount of money is held on behalf of some residents to assist them with paying for items such as chiropody and hairdressing. A sample check of the paper records against balances held was correct with one exception, which was 5p short, however a hole in the envelope was found and this shortfall, was to be corrected. Receipts for transactions made on residents’ behalf are kept and two signatures are obtained for all transactions to provide better safeguards for residents. While shortfalls in staff training were identified, staff confirmed that they had received training in safe working practices such as movement and handling. The pre-inspection questionnaire provided some information about maintenance checks. This confirmed that appropriate servicing and checks are made on things like the lift and fire safety equipment. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 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 OP7 OP8 2. OP12 Regulation 12 (1) (a, b), 15 Requirement Timescale for action 15/12/06 3. OP16 OP18 4. OP27 5. OP28 OP30 OP29 6. Care plans must be reflective of residents’ current health and welfare needs and sufficiently detailed to guide staff in meeting needs. 16 (2) (m, Arrangements must be made for n) residents to receive activities and stimulation taking account of their varying needs and choices. 13 (6) Arrangements must be put in place to ensure that residents are not placed at risk through failure to report or investigate concerns raised. 18 (1) (a) There must be sufficient staff on duty to ensure that residents’ do not have to wait long periods for assistance including toileting, and can exercise choice in their daily routines. 18 (1) (c) Staff must sufficiently trained to (i) meet the specific identified needs of residents’ living at Hinckley Park Nursing Home. 19 (1) (b) There must be evidence that satisfactory references and criminal record bureau clearances have been obtained prior to staff working in the DS0000001911.V314730.R01.S.doc 15/12/06 30/11/06 30/11/06 15/12/06 30/11/06 Hinckley Park Nursing Home Version 5.2 Page 26 7. OP33 24 (1) (a, b) home to protect residents’. Quality assurance systems to review and improve standards of care must be maintained. 15/12/06 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 OP2 OP12 OP31 Good Practice Recommendations Residents’ and/or their relatives should be provided with clear information about fee structures. Consideration should be given to any particular support needs residents’ may require in relation to maintaining their religion. Efforts should be made to maintain consistent management. Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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. Extracts may not be used or reproduced without the express permission of CSCI Hinckley Park Nursing Home DS0000001911.V314730.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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