Inspection on 02/08/07 for Honeysuckle House Nursing Home

This inspection was carried out on 2nd 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.

Other inspections for this house

Honeysuckle House Nursing Home 23/02/07

Honeysuckle House Nursing Home 11/03/06

Honeysuckle House Nursing Home 19/10/05

Honeysuckle House Nursing Home 05/04/05

Honeysuckle House Nursing Home 08/02/05

Honeysuckle House Nursing Home 21/10/04

Honeysuckle House Nursing Home 23/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Honeysuckle House Nursing Home 1a Oakthorpe Road Palmers Green London N13 5HY Lead Inspector Mr David Hastings Key Unannounced Inspection 2nd August 2007 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 Honeysuckle House Nursing Home DS0000027810.V348177.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. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Honeysuckle House Nursing Home Address 1a Oakthorpe Road Palmers Green London N13 5HY 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) 020 8886 8086 020 8886 0964 admin.honeysucklehouse@careuk.com manager.burroughs@careuk.com Care UK Community Partnerships Ltd Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Mental registration, with number disorder, excluding learning disability or of places dementia (32) Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2007 Brief Description of the Service: Honeysuckle House Nursing Home is a registered care home with nursing providing care to thirty-two older people with a diagnosis of mental disorder. Care UK Community Partnerships Limited manages the home and employs the staff. The home is owned by the London Borough of Enfield who retain contractual responsibility for funding the majority of the maintenance at the home as well as for purchase of furniture and equipment. The London Borough of Enfield block purchases the thirty-two places at the home. The home is a purpose built, two story premises that was opened in the1990s, originally to accommodate residents following the planned closure of a long stay hospital. The home provides both residential care and nursing care in two separate units. The ground floor contains a fourteen place residential unit that has twelve single bedrooms, one double bedroom and a range of communal facilities including its own lounge and dining room. The managers office, main kitchen and a large activity room are also situated on the ground floor. The first floor contains an eighteen place nursing unit that has sixteen single rooms, one double room, and a range of communal facilities including lounge and dining room. A passenger lift as well as stairs connects the two floors and both have an appropriate range of accessible bathrooms and toilets. Facilities throughout the home are fully accessible to wheelchair users. The home is situated in a quiet residential area close to the shops and amenities of Palmers Green as well as good public transport links. Placements at the home are bought by the local authority on a block contract basis and at the time of the inspection the fees were £504 for a residential placement, and £542 for nursing placement. Residents are expected to pay separately for hairdressing, newspapers and magazines and some toiletries. Copies of this report are available form the home or from the CSCI website. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Thursday 2nd August 2007 and lasted nine hours. We were assisted throughout the inspection by the recently appointed manager of the home who was very open and helpful. We spoke with six staff on duty during the inspection. The majority of people who live at the home have mental health problems or dementia. We spoke with eight residents of the home and observed the interactions between staff and residents. We inspected the building and examined various care records as well as a number of policies and procedures. The residents we spoke with said they were happy with the care and support they received. One resident told us, “It’s good here”. What the service does well: What has improved since the last inspection? What they could do better: Further work is needed to complete the refurbishment and decoration of the home to make sure that residents live in a better living environment. Three requirements relating to this have been restated, as they are not yet fully completed. One requirement concerning replacing worn curtains is still within the timescale set for action. Nine new requirements have been issued as a result of this inspection. The CSCI is particularly concerned that the repair of the fire alarm has taken too long and people have been put at risk because of Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 6 this. The responsibility of maintenance is with the local authority and better communication and procedures are urgently needed to ensure maintenance issues are dealt with in a timely manner. Urgent action is also needed in respect of the home’s electrical installations. It is concerning that Care UK has allowed these issues to continue for as long as they have. Care plans need to be updated regularly so that staff are kept informed of any changes to individual’s care needs. The procedure for dealing with any allegations of abuse at the home need to be reviewed to make sure that the Local Authority is alerted as soon as an allegation is made. The manager would benefit from training in this area. Staffing levels must not be reduced with out first notifying the CSCI and all written references must show clear evidence of their authenticity so that residents are protected. The results of any quality monitoring surveys must be published so that residents and potential residents to the home know how well the home is doing to improve standards of care. Some wheelchairs that are broken need repairing or replacing to ensure the safety of people using them. 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. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (6 not applicable) People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessments are completed before people move in to make sure that their individual needs can be met. EVIDENCE: We looked at the “Service User Guide”. This gives people information about the home and services and facilities available. Although the information was satisfactory it would be helpful to include a statement about how the home encourages people from different backgrounds to use this service. A good practice recommendation has been issued that the home reviews the service user guide to include an equal opportunities statement. A requirement from the last inspection that the details of the newly appointed manager are updated on the “Statement of Purpose” has now been complied with. We examined three assessments of people who have recently moved into the home. The manager told us that someone from the home would visit a prospective resident and carry out an assessment of their needs before they Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 9 moved in. These assessments were detailed and covered all the elements required by this Standard including the assessment of physical, emotional, social and cultural needs. These assessments were generally more detailed than the original assessments provided by the local authority. We also found that the information from these assessments was being recorded on peoples’ care plans as well. There was evidence that people moving into the home have a review of their placement after four to six weeks to see if they are happy at the home and whether they decide to move in on a permanent basis. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 10 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 and 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: We examined the individual plans of care for six people living at the home. These plans gave staff detailed information about how best to care for each person. People’s health, personal and social care needs were recorded on each plan. Care plans seen were “Person centred” in approach and contained information about how to maintain an individual’s privacy and dignity. Care plans also detailed people’s cultural needs. Generally these plans were being updated regularly however we did see some plans where the information was clearly out of date. For example one resident’s care plan recorded that he was unable to walk but we saw the resident walking around the home, on his own, Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 11 throughout the inspection. This positive improvement in the resident’s condition needed to be recorded in his care plan so that all staff are aware of the change in his abilities. A requirement relating to updating information in care plans has been issued in the relevant section of this report. The management and staff are to be commended for the clear improvement this person has made since being in the home. There were records on the residents’ files inspected of a range of health care checks by external health professionals. These included opticians, chiropodists and dentists. There was evidence of regular input from doctors including evidence of their attendance at the home. No one at the home has any pressure sores and the manager told us she would liaise with the tissue viability nurse if required. Pressure relieving equipment was being used for people who have been assessed as being at risk from developing pressure sores. Satisfactory records were examined in relation to the receipt, administration and disposal of medication. A good practice recommendation has been issued as a result of this inspection. Where residents with cognitive impairment are prescribed PRN pain control a detailed description of possible pain indicators may be of benefit and should be recorded on their medication chart. Records indicated that staff have undertaken medication training and only qualified staff administer medication at the home. We saw a number of examples of excellent staff interactions with people and staff were able to describe to us how they ensure the privacy of people they support. We saw staff knocking on resident’s bedroom doors before entering. People we spoke with told us that the staff were respectful and kind towards them. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 12 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 and 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides varied activities for people who use the service in order to keep them suitably occupied and engaged. The home encourages visitors, which ensures an interesting and lively atmosphere. Residents are able to exercise choice and control over their lives. The home provides people with a wholesome appealing balanced diet. EVIDENCE: We were impressed by the way residents could walk freely about the home and interact with both staff and other residents. The atmosphere of the home was relaxed and sociable. We spoke with the activities coordinator who told us she recently attended a course on dementia care and that this training had informed her approach to organising activities. Throughout the inspection we saw that residents were being kept suitably occupied and engaged. In the afternoon people were enjoying a birthday party for one of the residents. Social and recreational interests were being recorded on individual care plans. Care plans also described how staff are to meet the cultural and religious needs of people living at the home. This was a good practice recommendation that has now been complied with. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 13 We saw a number of visitors to the home during the inspection and the record of visitors indicated that they could visit at any reasonable time. This was confirmed by the home’s visiting policy in the service user guide. The home has regular residents’ meetings and minutes examined indicated that residents have a say in how the home is run. The minutes also provided evidence that residents are consulted about the menus in the home. Staff we interviewed were able to give us practical examples of how they offer choice to people living at the home. The kitchen was inspected. Fridge and freezer temperatures were being recorded and there were sufficient amounts of fresh fruit and vegetables available. The assistant chef was interviewed and had a good knowledge of individual resident’s dietary needs and preferences. Cakes are prepared for all residents’ birthdays and the meals we saw on the day of the inspection looked and smelt appetising. People who use the service confirmed that the food was good at the home and that they always get enough to eat. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 14 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 and 18 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. Further training in adult protection and a clearer procedure in relation to adult protection are needed to fully protect people living at the home from potential abuse. EVIDENCE: A satisfactory complaints policy was seen on display throughout the home. People we spoke to said they had no complaints about the service. Three complaints were recorded in the last twelve months and records seen indicated that these were dealt with appropriately and according to the policies and procedures in place. The home has a policy and procedure in relation to safeguarding adults from abuse. However the procedure was difficult to understand and did not make adequate reference to the local authorities own procedure. The manager did not appear to have a clear picture of what her responsibilities were in relation to notifying the local authority of any allegations of abuse at the home. We understand that the manger has been recently appointed and we feel that she would benefit from further training in this area. Two requirements relating to the adult protection procedure and training for the manager have been issued in this report. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 15 Staff we interviewed were able to give us examples of how people could be at risk from abuse and their responsibilities in relation to reporting any suspicions of abuse at the home. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 16 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, 24, 25 and 26 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean and hygienic. More work is needed to improve the living environment and to ensure the home is safe for all people living there. EVIDENCE: We toured the home with the manager and visited a number of resident’s rooms. We also looked at the bathroom and toilet facilities in the home. The home is currently being refurbished and decorated and a schedule of this refurbishment has been sent to the CSCI. Six requirements were issued at the last inspection relating to the refurbishment and decoration of the home. The local authority is responsible for the general upkeep of the home and we were pleased to see that work is currently being undertaken to meet these requirements. The manager told us that work will shortly be carried out to refurbish the bathrooms, decorate and carpet the quiet room, replace the floor Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 17 coverings and worn curtains throughout the home. A number of beds have been replaced. Three requirements relating to the upkeep of the home have been restated, as they have not yet been completed. One requirement is still within the timescale for action. The new carpet in the lobby area has improved the general ambience of the home. It was clear that the manager is working hard to improve the living environment for residents. We also looked at maintenance records, some of which were not satisfactory and are dealt with under the health and safety section of this report. We saw the laundry area, which has satisfactory equipment including facilities for sluicing bedding and clothes as required. All toilets and bathrooms contained anti-bacterial soap and disposable paper towels to limit the risk of cross infection. Training in infection control is also provided for staff. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 18 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 and 30 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. All the staff at the home work very hard to meet the needs of residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are generally in order to protect residents at the home. EVIDENCE: People who use the service told us they were happy with the staff at the home and we saw good interactions between staff and residents. On the day of the inspection there appeared to be enough staff to meet the needs of the residents. Staffing rotas seen matched the names of the staff on duty that day. The manager told us that due to a decrease in resident numbers, the number of staff on the nursing unit had been reduced by one. This information was not given to the CSCI and it is not acceptable for the provider to reduce staffing levels at the home without first contacting the CSCI. A requirement has been issued relating to this. Records examined indicated that over 50 of staff have completed their NVQ level 2 or equivalent. Staff were very positive about the training offered to them and staff training profiles examined indicated that staff at the home receive the training required Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 19 to do their jobs effectively. Where staff needed refresher courses in mandatory training we saw that these courses had been booked for later in the year. We examined the files of staff who have recently been employed at the home. All files contained the information required to protect residents including CRB disclosures and proof of identity. Some written references did not have a company stamp or letter headed paper included, which would provide the home with evidence that the references were genuine. A requirement has been issued relating to this in the relevant section of this report. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 20 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 and 38 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The newly appointed manager is working hard to improve the quality of care provided at the home. Residents have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded. The systems for monitoring health and safety at the home must improve to ensure the safety of both staff and residents. EVIDENCE: Staff and residents that we spoke with were positive about the new manager of the home. The manager, Ms Esther Oinubokiri is a qualified nurse and has recently been interviewed to become the registered manager of the home through the CSCI. The manager is qualified in dementia mapping. Dementia Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 21 mapping is a system of observing people with dementia who find it difficult to communicate in order to assess whether they are being cared for properly. We talked with the manager about how dementia mapping could form part of the home’s quality monitoring systems. There was evidence from monthly residents’ meetings that people who live at the home have a say in how it is run. A good practice recommendation has been restated that records should be kept of any action taken in response to residents comments and suggestions at meetings. The organisation, Care UK has systems in place to monitor the quality of care provided at the home including regular questionnaires, which are given to residents and their representatives. The results of these questionnaires must be published and made available to residents and other interested parties. A requirement has been made relating to this in the relevant section of this report. Some monies are kept by the home on behalf of a number of residents. A number of records were checked against cash held and found to be correct. We examined records in relation to health and safety. A fire drill had been carried out on 26/07/2007 and a fault was found with the fire alarm. The manager had informed Enfield Local Authority about the fault however there was still a problem with the fire alarm when we carried out this inspection. The manager told us that she had continued to report the faulty alarm since she discovered the fault. It is not acceptable to have a fault on the fire alarm for this amount of time as this puts both residents and staff at risk. The manager assured us she would sort the problem out that day and we were told that engineers were coming to look at the alarm that evening. The day after the inspection the service manager informed us that the fire alarm had been checked and the contractor had given assurance that the alarm was working, although a fault light was still registering on the panel. The service manager told us that this would be sorted out as soon as possible. Due to the swift response from Care UK regarding this matter the CSCI has been proportionate and judged this outcome group as adequate. However if any further breaches in health and safety matters arise and these are not responded to urgently this could lead to enforcement action being taken by the CSCI. We are very concerned about the amount of time it has taken to report and attend to this matter. A requirement has been issued that the organisation review it’s procedures in relation to reporting maintenance issues to the local authority to ensure that any problems are dealt with as a matter of urgency in order to protect both residents and staff at the home. This revised procedure must be sent to the CSCI. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 22 Another similar issue was found with the Electrical Installation Certificate. The certificate we saw was dated April 2007 and described the electrical installation of the home as, “Unsatisfactory”. There were 16 items listed as requiring maintenance action. We could find no evidence that any of these maintenance issues had been dealt with. Again it is not acceptable that these issues have not been addressed as a mater of urgency. A requirement has been made that the issues highlighted in the electrical installation inspection are dealt with and written confirmation of this must be sent to the CSCI. During the inspection we found a number of wheelchairs that were not working properly or had missing footrests. A requirement has been made that all wheelchairs that are broken are either repaired or replaced to ensure that the people using them are safe. An Occupational Therapist’s assessment may be helpful to ascertain the exact needs of people who use wheelchairs at the home. Other records we examined in relation to health and safety were satisfactory. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 2 X X 3 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 24 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 OP20 Regulation 23(2)(b) Requirement The registered persons must ensure that the quiet room, next to room 25 is redecorated and the carpet is replaced. (The previous timescales of 30/05/05, 28/02/06, 30/06/06 and 30/06/07 were not met.) This requirement is restated. 2. OP21 23(2) The registered persons must ensure that the bathrooms are refurbished as necessary. (Timescale of 30/06/07 not met) This requirement is still within the current timescale. 3. OP25 23(2)(b) The registered persons must ensure that the floor coverings are replaced throughout the home. (The previous timescales of 30/06/06 and 30/06/07 were not met.) This requirement is restated. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 25 Timescale for action 30/10/07 30/08/07 30/10/07 4. OP25 23(2)(b) The registered persons must ensure that all worn curtains are replaced where necessary throughout the home. (The previous timescales of 30/09/06 and 30/06/07 were not met.) This requirement is restated. 30/10/07 5. OP7 15(2) b The registered person must ensure that care plans are updated to reflect any changes in people’s condition and needs. This should ensure that staff are kept aware of how best to support people living at the home. 01/10/07 6. OP18 13(6) The registered person must ensure that the newly appointed manager undertakes training in the protection of vulnerable adults. 01/11/07 7. OP18 13(6) The registered person must ensure that the adult protection procedure is reviewed in order that it is easy to follow and makes reference to informing the Local Authority at the beginning of any investigation. 01/10/07 8. OP27 18(1) a The registered person must ensure that the CSCI is notified of any proposal to reduce staffing levels at the home before any reduction is undertaken. 01/10/07 Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 26 9. OP29 19(1) c The registered person must ensure that any reference received in relation to recruitment includes a company stamp or letter headed paper to provide further evidence of its authenticity. 01/10/07 10. OP33 24(2) The registered person must ensure that the results of any quality assurance surveys are published and made available to all interested parties. This includes residents and potential residents to the home. 01/12/07 11. OP38 23 (2) The registered person must ensure that the systems and procedures for reporting and dealing with any urgent maintenance issues are reviewed with the local authority responsible so that problems are dealt with quickly and residents and staff are protected. A copy of these procedures must be sent to the CSCI. 01/10/07 12. OP38 23(2) The registered person must ensure that the 16 items identified in the recent electrical inspection are resolved. Written evidence of this must be sent to the CSCI. 01/10/07 13. OP38 23(2) c The registered person must ensure that broken or incomplete wheelchairs are either repaired or replaced. 01/10/07 Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 27 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 OP32 Good Practice Recommendations It is recommended that to encourage an inclusive and empowering environment that notes from resident meetings should include staff responses to resident’s comments and requests, actions to be taken and matters arising from previous meetings. This recommendation was not reviewed. 2. OP1 The registered person should ensure that the home’s “Statement of Purpose includes an equal opportunities statement detailing how potential residents from diverse backgrounds are welcomed and encouraged by the organisation. 3. OP9 The registered person should ensure that where people with cognitive impairment are prescribed PRN pain control a detailed description of possible pain indicators are detailed on their individual MAR chart. Honeysuckle House Nursing Home DS0000027810.V348177.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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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