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Inspection on 03/08/07 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 3rd August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Residents` and relatives are happy with the staff team and appear to have developed good relationships with them. Staff were described as doing " a fantastic job". There is a thorough assessment process, which is carried out before a resident is admitted helping to ensure that the needs of those people admitted to the home can be met. Several relatives and residents` commented on the good "health care" and also the advice and support that is received from staff. The standard of the meals is very good; residents` have a choice and are happy with what is provided. The home is clean and comfortably furnished and visiting times are flexible enabling visitors to visit at times convenient to them, which helps to enhance residents` lives.

What has improved since the last inspection?

Management arrangements are more consistent and the Acting Manager who had just started work in the home at the time of the last inspection is still in post. An application to register her as the registered manager is being processed by The Commission for Social Care Inspection, which will formalise the management arrangements and give her more legal responsibilities for the management of the home and the care of the residents. Residents`, relatives and staff said the manager is approachable and that they are able to raise issues with her. This helps to ensure that any problems are identified and can then be addressed.

What the care home could do better:

Care planning and care records need to be improved to make sure that clear information about a residents` needs is available to staff reducing the risk of residents` not getting the care that they need. One of the main areas of concern raised by residents and relatives is the difficulty for people who rely on staff for assistance with moving and handling. They say that they sometimes have to wait for long periods for assistance to the toilet, which causes anxiety and distress. Residents` and relatives spoke with feel that this is because the home is understaffed. Advice has been given to look at the practical needs and outcomes for residents as part of a review of staffing levels. This was also raised at the inspection in October so it is of some concern that it remains a problem.Hinckley Park Nursing HomeDS0000001911.V340746.R01.S.docVersion 5.2At the time of the inspection there was no activity organiser and residents` said care staff did not have time to organise any stimulating activities, which made the days quite long. Staff training records were poorly organised making it very difficult to ascertain what training staff had received. Discussion indicated that shortfalls in staff training had been identified which the manager was trying to address.

CARE HOMES FOR OLDER PEOPLE Hinckley Park Nursing Home 67 London Road Hinckley Leicestershire LE10 1HH Lead Inspector Kathy Jones Key Unannounced Inspection 3rd August 2007 08:30 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.V340746.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.V340746.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 ** Post 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.V340746.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 19th October 2006 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 3 August 2007: Local Authorities who are funding residents are charged at a set rate of £339 per week plus any additional nursing contribution. The nursing contribution varies according to the assessed needs. Currently the contribution for those assessed, as having low needs is £44.30, medium needs £87 and high nursing needs £140. Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 5 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 - £550 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. Written information about fees is not currently provided within the service user guide, however this document is under review and advice has been given to include details of charges to assist people with making decisions about their care. Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 6 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 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 carried out on 19 October 2006 was reviewed and the findings taken into account when planning this inspection. The inspection visit was unannounced inspection and covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’ which involves selecting residents’ 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 residents’ who were not part of the case tracking process. An annual quality assurance assessment (self assessment) submitted by the manager was received and reviewed as part of the inspection process. Some views from residents’ 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 residents’ and their relatives. At the time of completion of the report questionnaires had been received from seven residents and five relatives and a telephone call had also been received. This information has been taken into account as part of the inspection. Shared areas and a sample of residents’ bedrooms were viewed during the inspection and observations were made of residents’ daily routines. A sample of records including staff files was viewed to check the adequacy of the recruitment process in protecting residents. Verbal feedback on the inspection findings was given to the Acting Manager during the inspection. What the service does well: Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 7 Residents’ and relatives are happy with the staff team and appear to have developed good relationships with them. Staff were described as doing “ a fantastic job”. There is a thorough assessment process, which is carried out before a resident is admitted helping to ensure that the needs of those people admitted to the home can be met. Several relatives and residents’ commented on the good “health care” and also the advice and support that is received from staff. The standard of the meals is very good; residents’ have a choice and are happy with what is provided. The home is clean and comfortably furnished and visiting times are flexible enabling visitors to visit at times convenient to them, which helps to enhance residents’ lives. What has improved since the last inspection? What they could do better: Care planning and care records need to be improved to make sure that clear information about a residents’ needs is available to staff reducing the risk of residents’ not getting the care that they need. One of the main areas of concern raised by residents and relatives is the difficulty for people who rely on staff for assistance with moving and handling. They say that they sometimes have to wait for long periods for assistance to the toilet, which causes anxiety and distress. Residents’ and relatives spoke with feel that this is because the home is understaffed. Advice has been given to look at the practical needs and outcomes for residents as part of a review of staffing levels. This was also raised at the inspection in October so it is of some concern that it remains a problem. Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 8 At the time of the inspection there was no activity organiser and residents’ said care staff did not have time to organise any stimulating activities, which made the days quite long. Staff training records were poorly organised making it very difficult to ascertain what training staff had received. Discussion indicated that shortfalls in staff training had been identified which the manager was trying to address. 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.V340746.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.V340746.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): 3, 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 provides assurances that the needs of people admitted to the home can be met. EVIDENCE: The content of the information available to help people to make a decision about moving into the home was not reviewed during this inspection as it was in the process of being revised. The annual quality assurance assessment completed by the Acting Manager acknowledges the need to improve the information to help relatives and residents understand the process of admission and the financial side of events,leading up to admission. As the information in the statement of purpose and service user guide is being revised by the organisation, advice was given to ensure that the information was specific to Hinckley Park. Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 11 Feedback from residents about the information they received before moving in to the home was mainly positive and most people felt that they had sufficient information. A resident commented in response to a survey that they had visited Hinckley Park prior to moving in and that all of their questions had been answered. The Acting Manager advised that copies of the last inspection report were available on request to residents’ and their relatives however following discussion she would make it more accessible to residents’ and their families. Care files for two recently admitted residents’ were looked at during the inspection and this showed that an assessment of the residents’ needs had been carried out before admission. The information gathered as part of the assessment included medical history and a physical and social assessment. The information appeared sufficient to help make a decision as to whether the residents’ needs could be met which reduces the risk of their needs not being met following admission. Hinckley Park Nursing Home DS0000001911.V340746.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ and relatives are happy with the healthcare provided however the lack of up to date care plans and records has the potential to put residents at risk of their needs not being met. EVIDENCE: Review of the responses in surveys received from a sample of residents’ 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 they do very well in all aspects of care”, “Care support varies depending on whether there is a full complement of staff”. From discussion with residents’ during the inspection, comments in the surveys and a telephone call from a relative the main issue of concern appears to be that staff are not available quickly enough when residents want to go to the toilet. “Toileting is causing a lot of anxiety because of waiting time”. This issue Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 13 was raised in the report of the inspection carried out in October 2006 and one comment received said that it had not improved since that time. The issue is included in the section of the report as it is about meeting residents’ personal care needs and maintaining their dignity. Views of relatives, residents’ and staff spoken with indicate that the problem relates to staffing levels, therefore a requirement is made under the staffing section. Review of a sample of residents’ care files confirmed that care plans are in place for residents’. Prior to admission a draft care plan is developed from the information gathered in the pre-admission assessment. More detailed care plans are then developed based on further assessments, which are carried out once a resident has been admitted. Care plans are considered to be important documents, which help to guide staff in providing consistent care, based on resident’s individual needs. Review of a sample of residents’ care plans identified that there is a variance in the standard of completion. For example a movement and handling plan for resident contained clear information about the equipment needed to assist the individual resident. However some other plans were very general and contained statements such as “discuss with daughter likes and dislikes and record”. Given that this resident had been identified, as being at nutritional risk it would be particularly important to take account of likes and dislikes as part of a dietary plan. Staff were seen to take the resident a liquidised meal in a beaker, however this was not included in the plan or related risk assessments. The care file for a resident with a pressure ulcer did not contain a pressure area care plan or a recent wound assessment record. The care file for another resident with a wound contained a clear care plan, which had recently been updated, however in some instances the wound care assessment had not been completed regularly. Although residents’ and relatives are happy with the health care provided it is important that improvements are made to the care plans, which support the care. The lack of available information makes it difficult for staff to provide consistent care and treatment and review the effectiveness of the treatment provided. A sample check of the management of residents’ medication found it to be generally good. There were some missing signatures on the drug administration record. However there is a good audit system with any discrepancies being identified and evidence that action is taken to address shortfalls. A sample check of the small amount of controlled drugs held against the records found that these were accurate. There was evidence to confirm that any concerns or information identified, which relate to the management of controlled drugs are reported to the relevant authorities. Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 14 Records show that referrals are made to various health professionals on behalf of residents. These include General Practitioners, District Nurses, McMillan nurses and Dieticians. 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.V340746.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 residents’ are happy with the quality of food provided. However the level of stimulation and activities is limited. EVIDENCE: Residents’ spoken with said they enjoyed the musical entertainment which is provided by an outside entertainer once a month. However they were unable to recall any other activities. At the time of the inspection there was no activities organiser and residents said that care staff do not have time to arrange activities. A relative in a questionnaire stated, “Not much time to do anything other than toilet/shower/bath and feed those confined to bed, therefore unable to have comforting chats with residents’ very little one to one interaction”, which confirmed this. A resident spoken with felt it would be helpful to have more mental stimulation, while another resident suggested that as they were confined to a wheelchair and their hands were stiff, an activity of exercises might be useful. Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 16 Discussion with the Acting Manager identified that she was intending to recruit a new activity organiser. Information provided in the annual quality assurance assessment identifies that plans for improvement include arranging more trips outside the home and further involvement within the home from the local community. Discussion with residents and relatives confirmed that there are flexible visiting arrangements and staff were heard to acknowledge and welcome visitors. Residents’ who are mobile are able to access all parts of the home and a resident 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. Residents’ spoken with were happy with the food provided. Observations of the lunch time meal confirmed that this was freshly cooked and looked and smelt appetising. Residents’ were all offered a choice of main meal. Hinckley Park Nursing Home DS0000001911.V340746.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 good. This judgement has been made using available evidence including a visit to this service. People feel that their concerns are listened to and complaints are taken seriously. EVIDENCE: A copy of the complaint procedure is available in the hall. Information received in questionnaires and through discussion with residents’ and relatives confirms that people feel able to raise any concerns that they may have and that they will be listened to. Residents and a relative have told the inspector that the Manager is very approachable. The Commission for Social Care Inspection has received no complaints since the last inspection. However information was received that social services had received a complaint, which was being investigated under safeguarding adult’s procedures. An action plan developed following the investigation indicates that the concerns raised were investigated, shortfalls were acknowledged and an action plan developed to address them. While complaints are taken seriously it was identified that when a relative raises a concern about the care of a resident that this is usually recorded on the resident’s care file. One of the drawbacks of this is that it is then difficult to gain a clear overview of recurring issues and collate information, which may Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 18 help to resolve the problem. For example concerns have been raised during this inspection about the length of time residents’ have to wait for assistance to the toilet. A relative has said that this problem has been raised on many occasions, however there was no information in the main complaint record. Advice has been given to the Acting Manager to review the current methods for recording and managing complaints and concerns to help provide an overview and identify factors, which may affect the quality of care provided. A staff member spoken with was clear about their responsibilities in relation to safeguarding residents’ from abuse. The staff member confirmed that they have also received protection of vulnerable adults training. Hinckley Park Nursing Home DS0000001911.V340746.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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this 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. There is also a conservatory, which leads to the garden, which has a patio area with seating. All areas seen were clean and comfortably furnished. Discussions with staff confirmed that there is a planned cleaning programme in place and information received in questionnaires from residents’ and discussion with them on the day Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 20 of inspection confirmed that there is a good standard of cleanliness and that staff take pride in maintaining it. Several residents’ are nursed in bed and some prefer to spend time in their rooms rather than the shared lounges and dining rooms. Residents’ wishes about where they spend their day are respected. Residents’ rooms are comfortably furnished and they are encouraged to bring personal items such as photographs and ornaments. Drinks and the call bell were within easy reach of a resident spoken with. Information received in the annual quality assurance assessment identifies that there is a programme for maintenance and servicing. A sample check of records confirmed this. The laundry is well organised and systems are in place for ensuring that clothing is appropriately separated before washing. This helps to reduce the risk of infection. Discussion with a member of the care staff identified that although they were clear about the need for using protective gloves and aprons and following good hygiene procedures to reduce the risk of infection, they had not received any specific training in infection control. Following discussion the Acting Manager she confirmed that she would ensure that information about infections was given to staff prior to training being organised. Hinckley Park Nursing Home DS0000001911.V340746.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 adequate. This judgement has been made using available evidence including a visit to this service. The improvements in the recruitment procedures provide better protection for residents however staffing levels and staff training need to be based on meeting residents needs. EVIDENCE: Positive comments were received about staff from discussions with residents and a relative. This is supported by comments received in questionnaires from residents’ and relatives. The concerns they have relate to the sufficiency of staff particularly in relation to meeting the needs of residents who are reliant on them for movement and handling. This issue is raised in the health and personal care section of this report. The following comment from a relative sums up other comments made “All the staff work very hard and do a fantastic job but sometimes there could be more of them, patients have to wait quite a while when they’ve pressed the buzzer sometimes due to being overworked and understaffed”. The above comments appear to be in conflict with the information received in the annual quality assurance assessment, which states that there is “adequate staffing for client group”. It also says that there have been no complaints received regarding staffing levels. There was no record of any complaints Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 22 about staffing in the complaint record, however due to the current method of recording without reviewing all of the residents’ files it is difficult to ascertain how may have raised issues that link to staffing. The findings of the inspection indicate the need to review staffing levels and deployment based on the outcomes for residents’. The annual quality assurance assessment identifies that only three the twenty permanent care staff have achieved a National Vocational Qualification (NVQ) or equivalent in care. Another two are working towards the qualification. The percentage of trained staff is very low; however there has been a small improvement since the inspection in October 2006. 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. At the time of the inspection information about staff training was in the process of being collated and the training matrix updated. It was not possible from the information available on the matrix and on staff files to confirm that all staff have received the necessary training to meet residents’ needs. Staff training records were also identified as a shortfall at the inspection carried out in October 2006. Discussion with staff and the Acting Manager indicated that there are currently shortfalls in staff training to meet the needs of residents’, which the Acting Manager was trying to address. A sample check of files for staff recruited since the last inspection confirmed that there is a thorough recruitment process in place and that criminal record bureau clearances and references are taken up prior to staff working in the home. This helps to protect residents. Hinckley Park Nursing Home DS0000001911.V340746.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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements are more consistent, which will help to raise standards of care to residents’. EVIDENCE: Standard 31 relates specifically to the registered manager and their experience and qualifications. At the time of the inspection there was no registered manager in post. However it is considered from the perspective of the adequacy of the management arrangements, as this is considered a key aspect of ensuring that residents receive appropriate care. Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 24 At the time of the inspection in October 2006 the Acting Manager had just started work following a period of temporary management arrangements. An application for registration of the manager is currently being processed the Commission for Social Care Inspection. Positive feedback was received from residents, relatives and staff about the approachability and accessibility of the Acting Manager. The organisation has comprehensive quality assurance processes in place to monitor the quality of care provided. Audits are carried out monthly by the manager and a validation audit is carried out every two months by the Operations Manager. One of the audits looked at during the inspection was the medication audit which appeared quite thorough and it details action to be taken to address shortfalls. An operations manager also carries out a monthly unannounced visit to monitor and report the conduct of the home and the care provided. A sample check of these reports indicated that some of the findings, for example those in relation to the care provided and care planning were similar to the inspection findings. An annual quality assurance assessment (self assessment) submitted by the Acting Manager has identified where improvements can be made. This inspection has continued to identify shortfalls, however consistent management, implementation of the identified improvements and action to address the issues raised in the inspection report will help to improve the lives of residents. No health and safety concerns were identified during the inspection. However review of the training records indicated the need to monitor staff training in safe working practices to ensure that all relevant training updates have been undertaken to keep residents’ safe. Hinckley Park Nursing Home DS0000001911.V340746.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 Hinckley Park Nursing Home DS0000001911.V340746.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 Timescale for action 30/10/07 2. OP12 3. OP27 OP14 4. OP28 Care plans must be reflective of residents’ current health and welfare needs and sufficiently detailed to guide staff in meeting needs. (This requirement with a timescale for compliance of 15/12/06 is outstanding from the last inspection.) 16 (2) (m, Arrangements must be made for 30/09/07 n) residents to receive activities and stimulation taking account of their varying needs and choices. (This requirement with a timescale for compliance of 15/12/06 is outstanding from the last inspection.) 18 (1) (a) There must be sufficient staff on 30/09/07 duty to ensure that residents’ do not have to wait long periods for assistance including toileting, and can exercise choice in their daily routines. (This requirement with a timescale for compliance of 30/11/06 is outstanding from the last inspection.) 18 (1) (c) Staff must sufficiently trained to 30/10/07 (i) meet the specific identified needs of residents’ living at Hinckley Park Nursing Home. DS0000001911.V340746.R01.S.doc Version 5.2 Hinckley Park Nursing Home Page 27 (This requirement with a timescale for compliance of 15/12/06 is outstanding from the last inspection.) 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 OP28 Good Practice Recommendations Efforts should be made to increase the number of care staff trained to a minimum of National Vocational Qualification level 2 or equivalent. Hinckley Park Nursing Home DS0000001911.V340746.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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