Inspection on 18/06/07 for Hulcott Nursing Home

This inspection was carried out on 18th June 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

Hulcott Nursing Home 05/05/09

Hulcott Nursing Home 12/01/09

Hulcott Nursing Home 15/10/08

Hulcott Nursing Home 23/09/08

Hulcott Nursing Home 13/06/08

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Hulcott Nursing Home The Old Rectory Hulcott Aylesbury Buckinghamshire HP22 5AX Lead Inspector Joan Browne Unannounced Inspection 18th June 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 Hulcott Nursing Home DS0000067231.V337433.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. Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hulcott Nursing Home Address The Old Rectory Hulcott Aylesbury Buckinghamshire HP22 5AX 01296 488229 01296 330834 hulcottnursing@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) Hulcott Limited ****Post Vacant**** Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49) of places Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New service Brief Description of the Service: Hulcott nursing home is located a few miles outside of the centre of Aylesbury in a quiet hamlet location overlooking a green. The home is registered to provide accommodation for up to forty-nine service users requiring nursing input. The building has been attractively arranged to provide a pleasant environment for the people living there, with good quality furnishing and fittings. Nine of the bedrooms are shared rooms for two people. The majority of bedrooms have en suite facilities and all but two rooms are fully wheelchair accessible. There are three lounge areas, a large conservatory and a quiet area by the main entrance. The grounds are well maintained with a patio area and backs onto farmland. There are no public transport links and shops are some distance away. The fees for the service range from £472.00 to £733.00 weekly Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 09:30 and was in the service for approximately nine hours and looked at how well the service was doing. It took into account detailed information provided by the service’s owner or manager, and any information that the Commission had received about the service. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. Ten service users, six relatives and two health care professionals replied to the Commission’s comment cards and their views are reflected in this report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector examined care plans and followed this by meeting with the individuals to see if the plan matched the assessed care needs. The medication system and accompanying records were examined along with other records required by regulation. Staff rosters were examined along with staff recruitment files, and training documentation. A tour of the premises was made. The inspector spent some time meeting with service users, staff and visitors. From the evidence seen it was considered that the home was providing an adequate service to meet the needs of individuals of various religious, racial or cultural needs. The inspector would like to thank everyone who assisted in this inspection in any way. What the service does well: The home ensures that service users are issued with contracts outlining the terms and conditions of occupancy. The home ensures that service users’ needs are assessed before moving into the home. Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 6 The home ensures that service users’ relatives and friends are made to feel welcome when visiting the home. The home ensures that service users live in a clean, pleasant and hygienic environment. The home ensures that there are sufficient staff on duty throughout the day to care for service users. What has improved since the last inspection? 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. Hulcott Nursing Home DS0000067231.V337433.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 Hulcott Nursing Home DS0000067231.V337433.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, 2 &3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service The home has a statement of purpose and service user’s guide in place. However, the documents need to be amended to ensure that the information provided to prospective people to use the service is accurate and reflective of the care provided. There was evidence, which confirmed that all prospective people to use the service needs are assessed prior to moving into the home and contracts are issued outlining the terms and conditions of occupancy. The home does not provide intermediate care. EVIDENCE: The home has a statement of purpose and service user’s guide. The information in both documents requires some minor amendments. For example, the statement of purpose states that the home provides nursing and residential care. The home is registered to provide nursing care and not Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 9 residential. The number of care staff working in the home and their experience is not stated in the section relating to staff experience and qualification. On page eleven in the service user’s guide the section relating to protection states the following: ‘The nurse in charge has had training in reporting any POVA issues to the appropriate team in Poole.’ This information is not correct and should be amended to reflect the appropriate safeguarding vulnerable adult team in Aylesbury. Five service users who responded to the Commission’s comment cards said that they did not received enough information about the home before moving in. This was discussed with the manager during the inspection and she confirmed that service users are now being sent a copy of the home’s statement of purpose with their contracts. It was noted that the home was caring for two service users whose first language was not English and one service user with an impaired vision. A recommendation is being made for the documents to be available in other formats to assist those with sensory deficit and whose first language is not English. A copy of a completed contract for a service user that was recently admitted to the home was made available for the inspection process. The contract outlined the terms and condition of occupancy, payment of care fees, services covered by fees including personal effects, personal mobility and insurance cover. Information in the home’s annual quality assurance assessment (AQAA) under the heading what the home does well indicated that the home’s pre-admission assessment process provides the opportunity for prospective service users and their relatives to visit the home, have a look around and participate in lunch if they wish to. Case tracking confirmed that the home has a pre-admission assessment process and an assessment tool in place. The assessment forms the basis of the care plans and a senior member of staff carries out all assessments. A service user that was recently admitted to the home and a relative was spoken to. They said that they were happy with the service that the home had provided so far. Although the individual did not visit the home before taking up the placement and depended on other family members’ decisions she was positive that the right home had been chosen and was looking forward to adjusting to her new surroundings. Hulcott Nursing Home DS0000067231.V337433.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 & 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home should ensure that care plans for people using the service are detailed and reviewed regularly to reflect changes in individuals’ care needs. Staff’s practice in the recording of medication should be consistent to ensure that people using the service are not put at risk of any potential harm. EVIDENCE: Case tracking highlighted that details in the three care plans examined relating to individuals’ health and social care needs were not recorded in a person centred approach. The detailing of the action required by staff to ensure that all aspects of service users’ health, personal and social care needs were being met was not always evident. The standard of recording depended on which member of staff was completing the care plan. Plans were not signed by service users or their representative to confirm their involvement in the process Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 11 Plans did not always reflect changes to individuals’ care needs. This was because of staff’s inconsistent practice to ensure that care plans, nutritional, tissue viability and moving and handling risk assessment were reviewed monthly. In one particular care plan examined there was a need to review an identified problem weekly. However, weekly reviews were not taking place. In one care plan seen the weight chart for the individual reflected that there was no monitoring of the individual’s weight since December 2006. When this was explored it was ascertained that staff were recording the information somewhere else. It is acknowledged that the home has been going through a transitional phase and new care documentation had been introduced. All staff will need to ensure that they fully understand the new care documentation and be accountable for their actions. It is acknowledged that the relief manager had identified weaknesses in the home’s care planning recording process and was making arrangements to review all care plans with service users and their relatives to ensure that they fully comply with best practice guidelines to reflect individuals’ diverse needs and to ensure that individuals are involved in the development of their plans. Service users who completed surveys said that they ‘always’ or ‘usually’ receive medical support that is needed. All service users were registered with a general practitioner who visits the home as and when required. The home arranges for dental and optical treatment to be provided on request from service users. There is a chiropodist that visits the home on a regular basis. Specialist medical treatment can be obtained via the general practitioner. The home ensures that service users at risk of developing tissue ulcers are provided with the appropriate aids and equipment such as pressure relieving mattresses and cushions to minimise the risk. It was noted that the care plan for a service user with tissue ulcers was not being reviewed weekly as indicated in the action plan. Staff should ensure that the care plan is reviewed as indicated and progress is recorded and monitored. It was observed that one service user being nurse in bed needed to be turned on a regular basis. Whilst the record did provide evidence of regularity, it also showed a period of time in one position. It is recommended that turning regimes be adhered to and accurate records are maintained. Jugs of juices and water were observed in lounges, which indicated that service users were offered fluids and encouraged to drink to ensure that they do not become dehydrated. Medication was being managed using a monitored dose system. The medication administration record (MAR) sheets were examined and no unexplained gaps were noted. However, some inconsistencies in staff practice were noted. For example, a handwritten entry on a MAR sheet was not checked by a second person, the strength and frequency of how the Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 12 medication should be administered was not recorded. When antibiotic treatments had been completed not all staff were dating and signing the entries. Staff were not using the appropriate code indicated on the MAR sheets when medication was refused or not available. Controlled drugs were safely stored and recorded correctly. It was noted that the home did not have the appropriate gadget for counting tablets, which posed the risk of tablets getting contaminated. It is recommended that the home obtain the appropriate gadget to prevent the risk of tablets getting contaminated. Service users on the day of the inspection looked well presented in clean attire and attention to detail. Some were enabled to wear jewellery to look their best. Staff were observed providing personal care in private. Comments within the surveys stated that the standard of personal care provided was satisfactory. One particular service user spoken to raised some sensitive concerns in relation to dignity issues, which highlighted a lack of staff’s cultural awareness. The acting manager recognises that there are shortfalls with cultural differences and has plans in place to improve outcomes for service users. Hulcott Nursing Home DS0000067231.V337433.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): 12, 13, 14 & 15 People who use service experience adequate outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The seating arrangements in the dining room needs to be reviewed to ensure that people who use services are assisted to have their meals in a relaxed and pleasing environment. A limited range of activities within the home and community means that people who use the service do not have a range of opportunities to participate in stimulating and motivating activities. The relief manager has showed a good understanding of the areas of weakness and there is a good capacity for the service to improve. EVIDENCE: It was noted in service users’ care plans examined that details of individuals’ interests, hobbies and pastimes were not recorded. This information needs to be obtained to ensure that activities provided meet service users’ needs and matches their expectations and preferences. The home had recently employed a new activity person and a basic activity programme had been drawn up. The acting manager said that work was in progress to develop the activity programme further to ensure service users are given the opportunity to take part in a variety of activities to meet their diverse needs. The home has an activity budget, which should come in useful Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 14 when planning activities outside the home. The home was in the process of organising its annual summer fare. Service users who responded to the Commission’s comment cards said that there were ‘always’ or usually activities arranged in the home that they can take part in. Throughout the inspection service users were observed occupying themselves by reading the newspaper or listening to background music. Others chose to remain in their bedroom and looked at television. One particular service user spoken to said that he enjoyed going for walks in the garden. Service users said that relatives are encouraged to visit and are made to feel welcome. There were no restrictions on visiting and they can be received in private in individuals’ bedrooms. There is a tea making facility in the dining room and visitors are able to make their own tea and coffee if they wish to. A church service is held in the home once a month for those service users who wish to attend and continue to promote their spiritual needs and take Holy Communion. The home has developed links with the local school and it was hoped that links would be developed further. Service users were encouraged to bring in personal belongings to maximise personal autonomy and choice. The inspector joined service users for lunch in the dining room. The tables were laid with tablecloths, condiments, napkins and the appropriate cutlery. A large number of service users were sitting at the table in wheelchairs, which made the room very cluttered and difficult for the staff to assist those people requiring assistance. Staff were observed talking over service users and speaking to each other in loud voices. Lunch time was not a relaxed and social occasion. It is recommended that the layout of the dining room be reviewed to enable service users to sit in comfort and enjoy their meal in a relaxed and calm environment. Service user’ views about the provision of food were variable. Some felt that the variety and quality of the meals provided were not satisfactory. Out of the ten service users who responded to the Comission’s comment cards. Five said that they ‘usually’ like the meals, three said ‘sometimes’ and ‘two’ said never. One particular service user felt that the meals provided were not meeting his dietary needs. This information was passed on to the relief manager to be addressed. The inspector met with the chef who confirmed that he meets with service users regularly to discuss their likes and dislikes. A senior personnel from the organisation’s hospitality team carries out regular food audits. There was no action plan in place as a result of outcomes of audits undertaken. Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 15 Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a complaints procedure to ensure that people who use the service and their relatives concerns are listened to and acted on. However, all staff need to be fully aware of the home’s whistle blowing policy to ensure that it is understood and consistently applied. EVIDENCE: The home’s annual quality assurance assessment reflected that the home had investigated six complaints, which were upheld. No complainant has contacted the Commission with information concerning a complaint about the service. The majority of service users who responded to the Commission’s comment cards said that they knew how to make a complaint. They also reported that they ‘always’ or ‘usually’ know who to speak to if they were not happy. It was noted that the home’s complaints procedure was included in the service user’s guide. However, a copy of the procedure was not displayed in the home. It is recommended that a copy of the home’s complaints procedure should be well displayed in the home so that it is accessible to service users and relatives. There has been one incident that was satisfactorily investigated under the safeguarding vulnerable adult procedure. The home has policies and procedures in place to protect service users from any potential risk of harm or abuse. The manager said that all staff had undertaken updated training in the safeguarding of vulnerable adult. Staff spoken to confirmed that they had Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 17 undertaken training and had a basic understanding of the action to be taken if an allegation was made. There were some gaps in their knowledge of the whistle blowing policy. Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home provides aids and adaptations to promote people who use the service independence. However, some maintenance matters need addressing to ensure that people who use the service continue to live in a safe and maintained environment. EVIDENCE: The home is located a few miles outside of the centre of Aylesbury in a quiet hamlet location over looking a green. The grounds are well maintained and provide a pleasant area to wander around and sit in and patio furniture and parasols are available. There is sufficient communal space for service users, all of which is smoke free. It was noted that there were areas in the home that could benefit from a facelift and it is acknowledged that the home has a five- year improvement maintenance plan for the renewal of the fabric and decoration of the premises. Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 19 A tour of the building highlighted that there were maintenance matters that needed to be addressed within a shorter timescale and a requirement has been made in this report for the following maintenance matters to be addressed: 1. The wall paper in the front lounge is lifting and need replacing 2. The paintwork in the toilet at the front of the building is flaking and requires scraping and repainting 3. An area in the carpet in the corridor near to the kitchen pose a tripping hazard and must be remedied 4. Chipped paintwork on skirting boards and bedroom and lounge doors need repainting There are toilets and bath/showering facilities with adaptations to assist service users with maintaining and promoting independence. Grab rails, hoists and a passenger lift are in place and a call system is fitted in the building. Bedrooms seen were personalised with service users personal belongings, pictures and mementoes that reflected their individual characters. In one particular bedroom the door was held open with a doorstopper. A requirement has been made in this report for the practice of holding the door open with this obstacle must cease. The laundry room is situated away from where food is prepared and stored and was in good order with the appropriate washing machines with the specified programming to meet disinfection standards. The area where general and clinical waste is stored was secure to prevent the spread of infection. The home on the day of the inspection was clean pleasant, hygienic and free from odours. Service users and relatives who responded to the Commission’s comment cards said that the home was ‘always’ or ‘usually’ fresh and clean. Additional comments were noted about the cleanliness of the home, which were varied. The following additional comments were noted: ‘Room is kept very clean and receives vacuum every day.’ ‘No complaints what so ever about condition of my room.’ ‘Plenty of dirt.’ ‘Used to be better.’ ‘Building and facilities are well maintained.’ ‘The home creates a friendly homely atmosphere to replicate as close as possible the environment that its patients lived in before they needed nursing care.’ Hulcott Nursing Home DS0000067231.V337433.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): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The training matrix should be developed further to ensure that it reflects the training undertaken by all staff to meet people who use the service basic needs. EVIDENCE: On the day of the inspection there were eight staff on duty in the morning, six in the afternoon/evening and four at night. Feedback from some people on comment cards indicated that staffing was sometimes insufficient at weekends. Additional comments noted about staffing were as follows: ‘ Very rushed sometimes don’t have time to spend time with residents unless it’s a job that has to be done.’ Although relatives felt that overall staff were caring and kind there were some concerns raised about the high percentage of non-indigenous staff employed in the home whose first language was not English which at times presented communication problems and lack of cultural awareness. The following additional comments were noted: ‘The staff are very caring and kind. Because so many of them are foreign there can be language difficulties and I am sure that elderly people with hearing problems have great difficulty in understanding what is being said to them.” ‘Nursing staff in particular are excellent. Language skills of carers from Far East are a bit variable. My father Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 21 sometimes has difficulty understanding them.’ The management team was made aware of comments raised. To improve outcomes for service users and improve communication links with staff and service users it is recommended that the proprietor address the communication problems raised by relatives. Two staff had acquired the national vocation qualification (NVQ) at level 2 in direct care. The manager said that work was in progress to ensure that the home achieved its 50 target of staff obtaining an NVQ level 2 qualification. Recruitment records showed that criminal records bureau clearance was in place for staff who were recently recruited and two references had been obtained. Personal identification numbers had been checked for nurses. Proof of identification had been obtained in the sample of files examined. There was evidence of permission to work for oversees staff and terms and conditions of employment. It was noted that the paperwork in files needed to be in better order and a recommendation is being made to this effect. Since acquisition the home has an in house trainer who also works as a trained nurse. On the day of the inspection a newly appointed staff member was undertaking induction training. The individual was supernumerary to the rota and confirmed that the training provided was thorough to enable her to do her job satisfactorily. Although staff confirmed that they had undertaken mandatory updated training and that they were being supported to understand their roles and responsibilities. The training matrix seen did not reflect this. It is required that the training matrix is developed further to reflect the training undertaken by all staff to meet service users’ basic needs. It is further recommended that the home provide equality and diversity training for all staff to ensure that they have a good understanding of the actions they need to take to meet individuals’ diverse needs and to promote equality and diversity. Hulcott Nursing Home DS0000067231.V337433.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): 31, 33, 35 & 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Audits systems need to be developed further to ensure that outcomes for people who use the service are improved and quality issues within the home are addressed. COSHH risk assessments and safety records need to be maintained to ensure that people who use the service safety is protected and promoted. EVIDENCE: The home does not have a permanent manager. The responsible individual had submitted the name of a peripatetic manager to the Commission that was appointed to work in the home until a permanent manager was appointed. This individual has now been replaced by another peripatetic manger. The Commission was not informed of the current changes and a recommendation Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 23 is being made for the Commission to be kept informed of any new changes. The relief manager was very experience and is a registered mental health nurse and has the registered managers awards qualifications. Relatives who responded to the Commission’s comment cards raised concerns about the frequent changes of managers since the home was acquired by the new owner and expressed a wish for the permanent position to be filled. The following additional comments were noted: ‘There have been several changes of managers recently I believe currently this position is being filled on a temporary basis. It would be nice to have someone permanent for continuity.’ Staff spoken to said that the relief manager was approachable and supportive. Having worked in the home for two weeks she had identified areas that required improvement and was committed to promoting equality and diversity in the service to ensure that individuals’ needs would be met. Since acquisition the organisation has had a food audit, stakeholders and hospitality audit undertaken. Action plans from audits undertaken have not been developed and a requirement is being made in this report for plans to be developed to ensure that outcomes for service users are improved and quality issues within the home are addressed. The home does not manage the service users’ financial affairs this is generally carried out by relatives or representatives. There is a financial system in place for the management of service users’ incidental expenditure. Service users are advised to deposit £30.00 for any extras that may be needed, which is deposited in a safety deposit box and kept in the administrator’s office. Appropriate records with signatures are maintained for all transactions carried out. Regular fire safety checks are carried out and records kept and these were made available for the inspection process. The servicing of the hoists, lift, and boilers was up to date. There was no evidence recorded to indicate that portable appliance testing (PAT) had been carried out on the electrical equipment in the home and the emergency call bell had been serviced. The home’s AQAA reflected that there was no written control of substances hazardous to health (COSHH) assessments in place for chemical solutions used in the home. A requirement is made for risk assessments to be developed for all COSHH solutions used in the home. The home must ensure that electrical equipment in the home has been tested and the emergency call equipment is regularly serviced. Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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. N o 1 Standard OP1 Regulation 4&5 Requirement 2 OP7 15(1) 3 OP14 16(2)(m) 4 OP19 23(2)(b) The statement of purpose and service user’s guide must be amended to ensure that information provided to prospective people to use the service is accurate. All people using the service must 31/07/07 have an up to date detailed care plan to ensure that they receive person centred support that meets their needs. Details of people using the 31/07/07 service particular interests, hobbies and pastimes must be recorded in care plans to ensure that activities provided meet their needs and matches their expectations and preferences. 31/08/07 To ensure that people using the services live in a safe and well maintained environment the following maintenance matters must be attended to: • The wall paper lifting in the front lounge must be replaced • The paintwork that is flaking in the toilet at the DS0000067231.V337433.R01.S.doc Version 5.2 Timescale for action 31/07/07 Hulcott Nursing Home Page 26 5 OP19 13(4) 6 OP30 18(c)(i) 7 OP33 24 8 OP38 13(4) 9 OP38 13(4) front of the building must be scraped off and replaced. The practice of keeping bedroom doors open with door stoppers or other obstacles must cease to ensure that people using services are as far as reasonably practicable free from hazards for their safety. Accurate records must be maintained of training undertaken by staff to ensure that people using the service are care for by staff who have been appropriately trained to meet their basic needs. An action plan from quality audits under in the home must be developed to ensure that outcomes for people using the service are improved and quality issues within the home are addressed. The home must ensure that COSHH assessments are developed for chemical solutions used in the home to comply with current legislations and to ensure that people using the service safety is protected. The home must ensure that all electrical equipment used in the home is regularly tested to comply with current legislation and to protect people using the service safety. 19/06/07 31/07/07 31/07/07 31/07/07 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000067231.V337433.R01.S.doc Version 5.2 Page 27 Hulcott Nursing Home 1 Standard OP7 2 3 OP8 OP9 4 OP9 5 6 7 OP9 OP15 OP16 8 OP18 9 10 11 OP27 OP29 OP30 12 OP31 People using services should have nutritional, tissue viability and moving and handling assessments reviewed monthly to ensure that their health care needs are closely monitored. Turning regimes for people using services who are nursed in bed should be adhered to thus ensuring that tissue ulcers are not developed. Handwritten entries on medication administration record sheets should be checked by a second person to ensure that people using the service receive the correct levels of medication. When antibiotic treatment is completed the person recording the entry should date and sign the entry to comply with best practice guidelines and to protect people using the service safety. The home should obtain the appropriate gadget for checking tablets to prevent the tablets for people who use the service from becoming contaminated. The seating arrangements in the dining room should be reviewed to ensure that people using the service have their meals in a relaxed and pleasing environment. A copy of the home’s complaints procedure should be displayed in the home to ensure that it is accessible to people using the service and they are clear about how to make a complaint. The home’s whistle blowing policy should be regularly discussed with all staff to ensure that they understand the policy fully to assist them in caring appropriately for people using the service. The proprietor should address the staff communication problems in the home to improve outcomes for people using the service. Staff’s personnel files should be better arranged to ensure that important documents in files are not lost. The home should provide equality and diversity training for all staff to ensure that they have a good understanding of the actions they need to take to meet people using the service diverse needs. The responsible individual should keep the Commission informed of any changes occurring in the management arrangements of the home. Hulcott Nursing Home DS0000067231.V337433.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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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