Inspection on 18/09/07 for Hooklands Nursing Home

This inspection was carried out on 18th September 2007.

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.

Other inspections for this house

Hooklands Nursing Home 26/03/07

Hooklands Nursing Home 20/04/06

Hooklands Nursing Home 05/10/05

Hooklands Nursing Home 03/05/05

Hooklands Nursing Home 08/12/04

Hooklands Nursing Home 04/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Hooklands Nursing Home West Bracklesham Drive Bracklesham Bay Chichester West Sussex PO20 8PF Lead Inspector Mr E McLeod Key Unannounced Inspection 18th September 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hooklands Nursing Home DS0000024158.V344354.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. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hooklands Nursing Home Address West Bracklesham Drive Bracklesham Bay Chichester West Sussex PO20 8PF 01243 670621 F/P 01243 670621 brian.mcdowell3@btinternet.com 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) Mr Mohammed Saleem Chaudhry Dr L Ezad Mrs Jeanette Louise McDowell Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th March 2007 Brief Description of the Service: Hooklands is a care home providing personal, social and nursing care for 27 service users over the age of 65. It is situated on the seafront at Bracklesham Bay, West Sussex. Bedroom accommodation is situated on the ground, first and second floors. The home has a vertical lift. There is a garden that has direct access to the beach. Access to the home is via a residential road and the home provides a small number of car parking spaces. There is a ramp for easy access into the home. There are a handful of shops near by and restricted public transport serves the village. The registered manager who is in charge of the day-to-day running of the home is Mrs Jeanette McDowell. The providers are Mr Chaudhry and Dr Ezad. The current fees range between £525.00 and £650.00 per week. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was arranged to follow up requirements made at the previous inspection and to undertake a further assessment of how the home is meeting the key national minimum standards. The visit was undertaken by one inspector and lasted for seven hours. Planning for the visit took into account information received on the service since the previous visit, including a CSCI annual quality assessment self-audit (AQAA) from the home which updated us on the service provided, and five CSCI survey forms returned to us by people living in the home. During the visit we spent time talking with six people living in the home, to the deputy manager, to four members of staff, and two visiting professionals. We also looked at four sets of care plans and other records relating to the care provided and health and safety in the home. We sampled three sets of staff recruitment and training records. We observed interactions between staff and people living in the home, and visited areas of the home including ten bedrooms and the main communal areas. What the service does well: What has improved since the last inspection? Improvements to the environment since the previous inspection include some new carpets, redecoration and refurbishment which have made the home a nicer place to live. The procedures for the recruitment of staff now better ensure that people in the home are in safe hands. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 6 Safety in the home has been improved by all radiators now having radiator guards. What they could do better: 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. Hooklands Nursing Home DS0000024158.V344354.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 Hooklands Nursing Home DS0000024158.V344354.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person has a written contact/statement of terms and conditions with the home. People are moving into the home without their full needs having been assessed. Intermediate care is not being provided. EVIDENCE: During this visit we looked at the contract/terms and conditions of residence for four people whose care we were reviewing. We found signed contracts to Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 9 be in place which provided advice to the person accommodated on their rights and responsibilities. The manager has told us in the annual quality self audit assessment (AQAA) for CSCI that each resident has a service user’s handbook in their room, and this tells them about the service provided in the home. The AQAA tell us that for prospective residents a full assessment is performed by a qualified nurse, and is discussed with the prospective resident and their relatives. At the previous inspection we found that admission assessments were not recording the interests and social needs of the person, which in turn was resulting in staff not being advised on how the person’s social needs and need for stimulation should be met. At this visit, we sampled three admission assessments and again found that these did not record the interests and social needs of the person. The requirement made in respect of this was found not to have been met. The AQAA advises that intermediate care supported by visiting physiotherapists or occupational therapists is provided in the home, but that the home does not have designated accommodation for intermediate care. Discussions with the deputy manager indicated that respite care is being provided, but that specialist intermediate care which includes a structured rehabilitation programme is not being provided in the home. Hooklands Nursing Home DS0000024158.V344354.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The person’s care plan is not setting out in detail the action which needs to be taken by care staff to ensure that all aspects of their health, personal and social care needs are met. People in the home are accessing the health care services they are in need of. The safety of people who are responsible for their own medication is not being ensured. EVIDENCE: Three sets of care plans were sampled. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 11 Some of the care plans sampled did not provide guidance for staff on how the social, emotional and psychological needs of the person would be met. For example, where records for one person indicated that they were suffering from a psychological illness (such as dementia) the care plan did not advise the person, their relatives and staff on how the needs resulting from this condition would be met. On one of the sets of care records sampled, a need to support the person to take walks was identified. This was not however recorded in the care plan, and therefore it was unclear if and how this support was being provided. Information provided in the AQAA by the manager and discussions with staff indicated that staff regularly attend meetings to support the specialist needs of people living in the home, such as continence link meetings and palliative care link meetings. We talked to a community psychiatric nurse who was visiting a person diagnosed with a dementia. The nurse said that good care was being provided which met the person’s needs. Care plans seen indicated that arrangements are in place for monitoring weight, assessing the risk of pressure injuries and wound care plans, all of which are being updated. The manager has told us that everyone in the home is given the opportunity to exercise and to take part in physical activity. During our visit it was noted that people were being encouraged to walk to the dining room, for example, and staff were allowing them the time they needed to do this. Staff we talked to gave examples of how they are ensuring that people’s privacy and dignity are being observed. An example given of this was that people are asked if they would prefer male or female staff to provide their personal care, and their wishes in this will be followed by staff. The manager advised us in the AQAA that each person has a GP and access to specialist medical, nursing, dental pharmaceutical, chiropody and therapeutic services. People and being supported by staff to attend hospital appointments. People we spoke to said they were receiving the medical services they needed. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 12 The manager has told us that only nurses are administering medicines, and that staff training in medicines is undertaken, and that there is a selfmedication policy and assessments. During our visit, the deputy manager advised us that one person holds their own medicines. We looked at the care records for the person, and did not find evidence that an assessment of risk and safety had been carried out, or that the arrangement had been recently reviewed. People living in the home who we talked to or who wrote to us (in response to our CSCI survey) said they found staff kind and considerate, and that their privacy and dignity were being respected. One person did however write in a survey form that “clothes are left inside out and not folded in drawers”, and therefore the provider will need to consider if improvements need to be made to the laundry arrangements in the home. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home cannot be sure that the home will meet their social, cultural, religious and recreational interests and needs. People in the home have some opportunities to maintain links with the local community. People are receiving a varied and nutritious diet, and enjoy their meals and mealtimes. EVIDENCE: The manager has told us that there is a monthly outing in a hired minibus and two theatre outings, and that people who are wheelchair-bound are taken out. One of the staff we interviewed said that he had attended training on providing activities, and had brought some of the ideas from the course to the Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 14 home. One example given was that where a person is keeping to his or her room, staff are ensuring that they take time to sit down and talk to the person during the day. While there was some evidence during the visit that the number of activities in the home had increased, there was a lack of information in care plans about how the individual social needs of the person were to be met The manager has told us that three full meals a day, including a cooked meal at 12:30, are offered to all people living in the home, and that specialist diets such as reducing diets and high calorie diets are provided for. During the lunch sitting we noted that soft diets were being provided. We talked to a dietician who was visiting the home and has been carrying out a study on the diet provided in the home. He said that in his opinion people at Hooklands were receiving a balanced diet. People we spoke to said they liked the food in the home. We observed a lunch sitting, and found that people were receiving the help they needed with the meal, and that the lunch was relaxed, sociable and unhurried. We noted on the day of our visit that people in the home who needed more calories were receiving mid-morning and mid-afternoon snacks such as bananas and custard. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are confident that their complaints will be listened to, taken seriously and acted upon. People in the home are not being safeguarded against abuse. EVIDENCE: We looked at the records of recent complaints held in the home, and discussed the outcome of a complaint with the resident concerned. We found that complaints are being looked into with fairness and thoroughness. One of the people living in the home who responded to our survey wrote that “all my concerns and requests have been attended to”. The home has policies and procedures in place which cover issues such as aggression, abuse, people’s money and valuables, and reporting bad practice. At the previous visit we found that the home’s policy and procedures on reporting allegations of abuse had not been followed. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 16 At this visit it was found that senior staff in the home now understood these procedures, and the requirement was assessed as met. We sampled training records for three care staff, and found no evidence that any of the three staff had undertaken training in the protection of vulnerable adults. We sampled records for money held on behalf of people living in the home, and found that these were being periodically audited by senior staff. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People in the home are not living in a safe, well maintained environment. Toilet, washing and bathing facilities are not meeting the needs of people living in the home. EVIDENCE: We visited the communal areas in the home and some bedrooms. While some improvement has been carried out to some bedrooms, furnishings in some bedrooms visited such as drawers, wardrobes and chairs were found to be in poor condition. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 18 Bathrooms and toilets were found to be not of a suitable standard. For example, in the ground floor bathroom the paint on tiles was peeling, the bath tap colour-coded cold ran hot water, and the decoration was in poor condition. A downstairs toilet was not accessible to staff in an emergency, and another toilet was being used for equipment storage and although unlocked was not accessible to people in the home. Another toilet seen had a loose toilet seat and the paint on the radiator was peeling. In the upstairs bathroom, the bath was rusted and had gouge marks which also had rusted. In the AQAA, the manager told us that pre-set valves are fitted in each room to minimise the risk of scalding to people living in the home. During our visit we hand-tested the hot water in some bedrooms, and found this to be at safe temperatures. In the bathroom on the first floor, together with the handyman and the deputy manager, we found the hot water tap in the bath to be very hot, and an immediate requirement was made concerning this. The registered person Mr Chaudhury advised us by fax that within 48 hours this fault had been corrected. We visited the laundry which we found to be suitably equipped, and staff told us of the arrangements in place for infection control, safe handing and disposal of clinical waste, spillages and protective clothing. At the previous visit, we found that some radiators were not guarded and could have been a risk to people in the home. Improvements to the home since then have included the fitting of radiator covers, and this requirement was found to have been met. At the previous visit we required that a programme of redecoration and repair be put in place. Since then, improvements made include new furniture in eight bedrooms, new carpets in four bedrooms, six bedrooms have been redecorated, and two further pressure-relieving mattresses purchased. We visited some of these bedrooms, and found the improvements had been carried out to a good standard. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 19 Improvements to communal areas have also included double glazing and redecoration. During our visit the deputy manager advised us that the redecoration plan for the home includes the redecoration of halls and stairwells, and some replacement furniture and carpets in bedrooms. The requirement made that the provider have a redecoration and repair programme was found to have been met. However, during this visit as well as furniture in some bedrooms and decoration and fittings in toilets and bathrooms in poor condition, the need for external repair was noted. For example, we found external walls with crumbling plaster, and wooden steps on an external fire escape which were broken and splintered. New requirements have therefore been made concerning the need for the proper upkeep of the premises and grounds. All parts of the home visited were found to be clean and hygienic, and people living in the home responding to our survey said the home was usually fresh and clean. Hooklands Nursing Home DS0000024158.V344354.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs are met by the numbers and skill mix of staff. People are supported and protected by the home’s recruitment policy and practices. Staff are not receiving all the training they need to ensure the people cared for will be safe and protected. EVIDENCE: The manager has told us that there is a nurse on duty on the premises 24 hours a day, and that there are five carers each morning, three in the afternoons and two at night. The manager tells us that an extra carer is on duty on activity days, and that for outings two or three carers are present. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 21 On the day of the visit there were sufficient numbers of staff on duty to meet the care needs of the people accommodated. One of the people responding to our survey wrote that “help is always available 24 hours”. The manager has told us that of 20 care staff, seven have achieved the national vocational qualification (NVQ) at level 2 or above, one is presently undertaking NVQ2, and two carers will commence their NVQ2 training in September 2007. At the previous visit we made a requirement that recruitment procedures be improved to ensure that people unsuitable to work with vulnerable adults are not employed. The manager has told us that all staff who have worked in the home in the past 12 months have had satisfactory pre-employment checks. During this visit we looked at three sets of recruitment records, and found that satisfactory references and checks had been obtained. The requirement made at the previous inspection concerning recruitment procedures was found to have been met. It was noted during the visit that most staff on duty were not wearing any identification, which we suggest would be helpful to people living in the home and to visitors. The manager has told us that all catering and care staff have received training in safe food handling. Staff we interviewed said they were receiving training which met their development needs, and had a good knowledge of the home’s policies and procedures and a positive attitude towards their work. However, training records seen indicated that training in some core topics, such as safeguarding adults, had not been provided for all staff. Hooklands Nursing Home DS0000024158.V344354.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Hooklands are not being protected by the fire and environmental safety arrangements in the home. The views of people living in the home are contributing to plans for improvement. EVIDENCE: The Registered Manager is a qualified nurse and holds the registered manager’s award. She has advised us of recent training she has undertaken to update her managerial and nursing skills. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 23 The manager has told us that feedback is gathered from people living in the home through an anonymous questionnaire and from views expressed at the twice per year meetings with residents. The manager has advised us of the outcomes of the most recent survey, and what will be done to make improvements in the areas identified in the survey as needing improvement. Insurance cover is in place for public liability, damage to or loss of assets, replacement of fixtures, fittings and equipment, and loss of earnings to a minimum of £5m. The manager has told us that written records are maintained of all financial transactions for people in the home whose finances are managed by the home. We sampled some of the financial records for people who have amounts of money held for them by the home, and noted that senior staff are periodically checking the records. The deputy manager advised us during the visit that she and the registered manager have attended training on staff supervision. The manager has told us that staff now have formal supervision in the office every eight weeks, together with an annual appraisal. We sampled some supervision records which indicated that a system for sitdown supervision for staff is now in place. At the previous visit we found that notifications of incidents the home is required to send to CSCI under the Care Homes Regulations 2001 had not been sent. It was identified during this visit that the previous week three incidents requiring notification had taken place. Senior staff we talked to were unclear about when a notification should be made, and advised us that only one of the three incidents had been reported to us. The previous requirement made concerning the notification of incidents was found to have not been met. The manager has told us that arrangements and training are in place to ensure safe working practices for all the staff, including manual handling, fire safety, first aid, food hygiene, infection control, and the storage and disposal of hazardous substances. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 24 We looked at the environmental risk assessments undertaken by staff since the previous inspection, when a requirement concerning this was made. We noted that the home has improved its’ guidance to staff on some of the environmental hazards in the home, such as the slope leading down to the dining room. However, there were no records which would show that a person trained to recognise safety hazards in the home (in people’s bedrooms, for example, or trip or mobility hazards such as the crates blocking a fire exit which we saw) is undertaking regular (monthly, for example) checks. The requirement made concerning environmental risk assessments was found to have not been met. At the previous visit we made a requirement that the home consult with the fire service concerning procedures for evacuating the dining room. During this visit, staff told us that consultation with the fire service had taken place, and that resulting from this a key is no longer needed for the dining room fire door which can now be opened by pulling a handle. Staff also told us that a fire emergency light for the dining room has also been ordered. The previous requirement made concerning fire arrangements in the dining room was found to have been met. During our visit, staff told us that the door to the external fire stairs from the second floor was not in use due to rusted hinges. Staff advised us that a new door was on order but had not yet arrived. An immediate requirement was made concerning the need for the fire door to be made operable, and we received a fax from the responsible person Mr Chaudhury to advise us that the door had been made operable within 48 hours of the requirement being made. Staff told us that three residents are presently accommodated on the second floor, including one person who has very limited mobility. We asked staff how this person would negotiate the stairs down to the fire exit and staff told us this would involve a blanket lift by two staff. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 25 Given that we are advised there are only two staff on duty overnight in the home, the provider needs to consider if the safety of the person could be properly arranged in the event of a fire (at night, for example) and make fire safety plans accordingly. We sampled records for gas safety, personal electrical equipment and hoists and found these to be up to date. We found that there were no records to indicate if fire extinguishers had been serviced when the service check had been due. We sampled records of accidents in the home, and found that senior staff were checking these to see if any preventative measures could be put in place. Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 26 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 3 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 3 1 X X 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 1 Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14 Requirement Resident’s social history must be obtained at the point of admission and included as part of their overall care plan. (The previous timescale for this requirement of 26/03/07 was not met) 2. OP38 37 Incidents must be reported to the commission as appropriate under Regulation 37 of the Care Homes Regulations 2001. (The previous timescale for this requirement of 26/03/07 was not met) 3. OP38 23(2)(b) (c) A formal documented system to 05/11/07 indicate how often risk assessments of the premises and working practices are undertaken must be implemented and available for inspection. (The previous timescale for this requirement of 3/04/07 was not met) 05/11/07 Timescale for action 21/12/07 Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 28 4. OP7 15 5. OP9 13.2 6. OP12 16.2 (m) 7. OP30 18.1 (c) 8. OP19 23.2 (b) 9. OP19 23.2 (d) 10. OP25 23.2 (j) 11. 12. OP38 OP38 23.2 (b) 13.4 (c) 13. OP38 23.2 (c) The service user’s plan must set out in detail the action which needs to be taken by care and nursing staff to ensure that all aspects of the health, personal and social care needs of the person accommodated are met People responsible for their own medication must be protected by the home’s procedures for dealing with medicines The home must consult residents about their social interests and make arrangements to enable them to engage in local, social and community activities The registered person must ensure that staff receive the training they need to protect people in the home (to include training in safeguarding adults) The registered person must ensure that the premises are kept in a good state of repair externally and internally The decoration and furnishing of bedrooms, bathrooms and toilets must meet the needs of the people accommodated A safe supply of hot water must be provided in all parts of the home to which residents have access. The hot water in the bath on the first floor to be made safe The door to the fire escape from the second floor to be made operable The provider must liaise with the fire service concerning the immediate safety of residents sleeping on the second floor Fire equipment in the home must be serviced at intervals recommended by the manufacturer 21/12/07 05/11/07 21/12/07 21/12/07 21/12/07 21/12/07 20/09/07 20/09/07 19/09/07 05/11/07 Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 29 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 All staff should wear identification while undertaking their duties Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Hooklands Nursing Home DS0000024158.V344354.R01.S.doc Version 5.2 Page 31 - 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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