Inspection on 04/01/06 for Hygrove House Nursing Home

This inspection was carried out on 4th January 2006.

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

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

Other inspections for this house

Hygrove House Nursing Home 20/02/07

Hygrove House Nursing Home 16/05/06

Hygrove House Nursing Home 17/05/05

Hygrove House Nursing Home 19/11/04

Hygrove House Nursing Home 09/06/04

Hygrove House Nursing Home 12/01/04

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

CARE HOMES FOR OLDER PEOPLE Hygrove House Nursing Home Minsterworth Gloucester Glos GL2 8JG Lead Inspector Sharon Hayward-Wright Announced Inspection 4th January 2006 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 Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 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. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hygrove House Nursing Home Address Minsterworth Gloucester Glos GL2 8JG 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) 01452 750716 hygrovehouse@highfield-care.com Southern Cross Care Homes No 2 Limited Mrs Rita Harris Care Home 48 Category(ies) of Dementia - over 65 years of age (48) registration, with number of places Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. NVQ 4 to be completed by the end of February 2006. Manager to access and start a post registration course in caring for older people with dementia by the end of February 2006. Date of last inspection Brief Description of the Service: Following a recent merger between Highfield Care and Southern Cross, Hygrove House is now part of the Southern Cross Group. Hygrove House sits back off the main A48 Gloucester to Chepstow road in Minsterworth. The house itself is a large extended period building surrounded by extensive gardens, with views over the surrounding countryside and Gloucester City. At the time of inspection the majority of the redecoration work had been completed and further refurbishment work was still awaiting completion. The Home cares for elderly people who suffer from a dementing illness. The building is on three levels and has a passenger lift including stair lifts where required. Many of the Service Users are prone to wander and can do so freely within safe areas, which are secured with keypads on the doors. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection by three inspectors, took place over 6 ½ hours on one day in January 2006. Service users where able were spoken with to gain their views on the home; the care of five service users was examined in detail and staff members were also spoken to, as well as the Registered Manager and Deputy Manager. One letter from a relative was received prior to the inspection. Staff were observed going about their duties and interacting with each other and service users. The requirements and recommendations made at the last inspection were followed up and records relating to the homes’ Statement of Purpose, Service Users Guide, terms and conditions, service users care, duty rotas, staff training, complaints, activities, personnel files, and servicing of equipment were inspected and a tour of the home took place with a number of service users rooms inspected. The inspectors have received a number of comments from relatives and these include the difficulties with the laundry system Medication was examined in detail by the Pharmacist inspector for the Commission for Social Care Inspection and a separate report has been sent to the home and Southern Cross. What the service does well: What has improved since the last inspection? Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 6 The standard of care plans has improved with more individualised care plans, however all service users must have care plans devised for all problems identified. The standard of vetting and recruitment practices has improved with all the required checks being undertaken to potentially reduce any risks to service users. The staff felt there has been an improvement in the variety of food provided to service users as they are more settled at meals times. Since the last inspection a section of garden has now been made secure so service users are able to wander outside in the warmer weather. The home has started to adapt the environment for the service users, for example painting doors different colours. Systems are now in place to ensure staff are appropriately supervised. In the year 2005 seventeen new members of staff started work at the home, which has caused concern for relatives and visitors to the home, however this is starting to bring a good match of staff to ensure consistency for service users. The homes Statement of Purpose and Service Users Guide contain detailed information about the service provided, however the inspectors could not find evidence that a number of services offered are taking place. What they could do better: As the home does not have a designated person to provide activities at the present time, this is left for staff to arrange, however if staff are busy service users will not be provided with activities. The home has training programme in place and a lot of training has been provided in the last year, however not all staff have undertaken all the training which could result in inconsistencies with staff capabilities. The home was found to have an issue with odours especially in service users rooms and this could be smelt on entering the home even with the use of air fresheners. Thus not providing service users with a pleasant or homely place to live. The refurbishment of the laundry has been ongoing for a period of time and during this inspection the inspectors had grave concerns about the safety of Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 7 the member of staff working there. The Health and Safety Executive were contacted. The home has set its own agreed staffing limits, however from reading the staff duty rotas the home has been running under their agreed limits. The majority of comments received from visitors about the home are that they felt there is not enough visible staff to meet the needs of the service users. 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. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5 The home’s Statement of Purpose and Service Users Guide provide service users and prospective service users with details of the services the home provides enabling an informed decision about admission to the home. However anomalies have been found in some of the statements made in the Statement of Purpose. Arrangements are in place to ensure prospective service users and their family/representatives can feel confident that the needs of the service user will be met on admission to the home. EVIDENCE: The home’s Statement of Purpose and Service Users Guide has been reviewed following the merger with Southern Cross. Both documents contain detailed information about the services provided by the home. However information is missing from the Service Users Guide, this is a copy of their terms and conditions and contract. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 10 The Statement of Purpose contains information about several services, however the inspectors did not see any evidence that they are taking place. These are: • That the home writes to new service users to confirm that they can meet their needs. • That within six weeks a placement review takes place for new service users, and if the service user has a Care Manager they are invited. Otherwise the named nurse will organise a multi-disciplinary review and then 6 monthly thereafter. • Service users meeting are held monthly and minutes are displayed. • Relatives meetings are taking place monthly and minutes are displayed within the home. • The Home Manager holds weekly ‘surgeries’ out of hours to give service users relatives and staff an opportunity to meet privately. Details of these are displayed within the home and within the reception area. The home must also add to their registration categories the number of service users they are able to accept. It is recommended where the qualifications list mentions dementia care there is more details to describe what this entails. The home has been sending the inspector copies of their pre admission assessments of any proposed service users, including how the home plans to meet their needs. Therefore this was not examined at this inspection. Service users (where able) and their relatives/representatives are encouraged to visit the home prior to moving. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 There is a clear and consistent care planning system in place, however care plans must contain adequate information for staff to satisfactorily meet service users needs Arrangements are in place for service users to access some health services via the home, however service users do not always receive specialist care or information provided from other sources. EVIDENCE: The care of 5-service users care was examined in detail. Since the merger with Southern Cross the home has nearly completed transferring their care plans on to Southern Cross’s format. Two service users whose care was examined in detail had pressure sores and wounds. Both of these service users had a physical and social assessment of need and detailed descriptions of their wounds, however both stated that wound mapping and photographs had been taken but these are not stored in the home. The Tissue Viability Nurse (TVN) has taken these with her. As the care plans stated these have been completed copies must be stored in the home to assist the staff in monitoring the ongoing condition of the wounds. One service user required care plans for personal hygiene and continence. The other service user requires a care plan Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 12 for infection control. Since the last inspection improvements have been seen with the care plans inspected, as they contained more individualised care and looked at addressing the service users mental health needs. Two care plans had ambiguous statements in them, one said ‘monitor for side effects and report to nurse in charge’. The care plan does not state what the side effects are. Another care plan for personal care says ‘ensure clothing is maintained to high standards’. These statement can be confusing to staff and there is no way to measure against these to see if they are happening when reviewing care plans. The care plans examined all had risk assessments in place for pressure sores, moving and handling, nutrition, falls and continence. Evidence was seen of regular reviews, however one of the continence assessments was not dated when first devised and one risk assessment for immobility and pressure area care devised in September 2005 had no documented reviews. Evidence was seen of health professionals’ involvement in service users care especially the two service users with pressure sores and wounds. These included the TVN (Tissue Viability Nurse), Community Nurses and The Care Home Support Team. It is recommended that the home request copies of Care Programme Approach documentation from Mental Health services where this is applicable. At the present time the home is experiencing difficulties with medical services and they feel a number of service users are not being referred to specialist services to assist in their care. Because of this the National Service Framework for Older People is not being met as described in the Department of Health’s publication ‘Everybody’s Business’. One of the inspectors has received a letter from a relative expressing their concern over the medical services provided to their relative living in the home. West Gloucestershire Primary Care Trust is looking at ways of improving the situation. Medication was examined in detail by the Pharmacist inspector for the Commission for Social Care Inspection. A separate report has been complied and sent to the home and Southern Cross. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 & 15 There was some evidence that activities are taking place, however this could be compromised without a designated person to organise them. Service users are helped to make choices over their lives within the limitations of their ability. Dietary needs of the service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The homes activities coordinator is on long-term sick leave. During the inspection there was music and movement taking place and the inspector was told this happens every day. At Christmas a carol concert took place and number of service users attend the local vicarage for tea. Religious services are provided. One inspector saw a ‘scrapbook’ that contained details of one of the service users lives. In care files some service users had their interests recorded but this was not completed in all. No records were seen relating to activities provided and the inspectors are concerned that as there is no one allocated to undertake activities and the staff are very busy they will not take place. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 14 Service users personal possessions were seen in their rooms. Service users choice may be limited due to their medical condition. One of the inspectors discussed the menus with the chef as they contained a varied diet and some of the choices offered were not written on. The chef is trying a number of new recipes and has found them to be a great success with the service users. He is working on a four-week rotational menu but has decided to make changes to prevent the menu becoming boring. Comprehensive food records are not being kept since the last inspection as they have had a change of chef. Any changes to the menu must be documented as well as any service user receiving a special diet. Sandwich filling and types of vegetables used must also be included. See standard 37. It is strongly recommend that records of cleaning schedules are maintained and a hazard analysis. Records of fridge, freezer and food temperatures were seen. Lunchtime was not observed at this inspection, however staff commented that service users appear to be more settled at lunchtime following the implementation of the change in menus. The inspectors received several comments from visitors, one felt the evening meal was always sandwiches and cake but the Chef said they do offer other choices but as the food records were not up to date this could not be checked. Another visitor said their relative did not always receive their meal in the evening. The Deputy Manager said this is not true but as no food record chart is maintained again it was difficult to prove otherwise. Records will now be maintained of when this service user receives their meal. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 There is a complaints system in place with some evidence that views expressed by service users relatives/representatives are listened to and acted upon. Arrangements are in place for protecting service users from the possible risk of harm and abuse. EVIDENCE: The Commission for Social Care Inspection received 5 complaints about the home and these were forwarded to Southern Cross for investigation. One complaint is ongoing at the time of the inspection. A thorough investigation was undertaken for each complaint and where necessary the appropriate action plans put in to place. The feedback given to the inspector following some of these complaints was that they felt their concerns had been listened to and addressed. The home has provided adult protection training to a large percentage of their staff but there are still some that require this training. A number of staff was asked questions about adult protection issues and they were able to provide the correct answers. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home has started to be adapted to meet the needs of the service users, however the cleanliness of the home does not provided service users with a homely and pleasant place to live. The laundry arrangements need reviewing to provide a service to the service users that meets their needs. EVIDENCE: A tour of the environment took place with the majority of service users examined. A small number of maintenance issues were identified, these are: • On the top floor exposed wiring was seen on one of the automatic closers on the fire doors. This was reported to the Registered Manager on the day of the inspection. • Room 52 and 30 had cracked windowpanes. • A number of service users’ doors to their bedrooms were seen to be closing quickly, this could be potentially a place service user at risk of being injured. This was reported to the Registered Manager during the inspection. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 17 There were numerous maintenance issues relating to the laundry. Due to the seriousness of the situation this was reported the Health and Safety Executive. Protective clothing was not available in the laundry area Concerns received from relatives of the service users is that service users do not have many of their own clothes in their wardrobes and are often wearing other service users clothes. This issue has been ongoing for long period of time and the arrangements of the laundry need to be reviewed to address these concerns. The home has started to adapt the environment to meet the needs of the service users; this includes service users having their bedroom door painted in the colour of the front door at their own home. There were a large number of chair cushions missing from service users rooms; the staff in the home said they were being cleaned at the time. A number of rooms had odours and this could be smelt on entering the home despite the use of air fresheners, this was brought to the attention of the Registered Manager during the inspection. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 After a period of instability in staffing, there is starting to be a good match of staff offering consistency of care within the home. Training opportunities have been provided for staff to improve their skills but there are inconsistencies with not all staff receiving training. Since the last inspection the standard of vetting and recruitment practices has improved again with appropriate checks being carried to reduce any potential risk to service users. EVIDENCE: The duty rotas were seen as evidence of staffing levels. The home can have 47 service users but at the time of the inspection, 43 service users are living at the home. The home has set their staffing levels. From examining the off duty the home is working under their agreed levels, however Southern Cross is looking to bring in staff to increase the numbers. The majority of comments received about staff from relatives and other visitors to the home is that there is not enough staff to care for the service users. The home must ensure that they have the required number and skill mix of staff to meet the needs of the service users. The Care Home Support Team are heavily involved with a service user who has complex needs. Once they withdraw from the home the staffing levels will have to increase again to meet the needs of this service user. The home does have several staff members on long-term sick leave. One visitor to the home said there has been a high turn over of staff in the recent months. From the pre inspection questionnaire in the year 2005, 17 Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 19 new staff members started work at the home. Other comments about staff were very positive about the way they relate to the service users. The home has 1 member of care staff with NVQ 2 and 2 care staff undertaking this training. Four members of staff from overseas are qualified nurses in their own country. Personnel files of six members of staff that have started at the home since the last inspection were examined. All contained the correct information as required under the Care Homes Regulations. The training matrix for the staff was examined, whilst a range of training has been provided, there were gaps where some staff had not done certain training. To ensure that all staff are competent in their roles they must receive training for the tasks they are to perform. The Registered Manager is going to look at addressing this as a matter of urgency. Only one induction booklet was available on the day of the inspection. Southern Cross has devised their format for induction training based on the National Training Organisations specifications. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35, 36, 37 & 38 Systems are now in place to ensure staff receive appropriate supervision. So far as is reasonably practicable the health, safety and welfare of service users and visitors are promoted and protected; however concerns have been highlighted with the safety of staff working in the laundry. EVIDENCE: Standard 35 was not examined in detail only a requirement issues at previous inspections for the home to maintain records of service users subject to the Power of Attorney process. Evidence was seen that this has been addressed. The home has a timetable for staff supervision; records of a session were seen. The home is hoping to meet the recommended six times per year for care staff and other staff as their normal management arrangements. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 21 As discussed in Standard 15 comprehensive food records are not being as kept as required under Regulation 17 and Schedule 3 of the Care Homes Regulations. Records were seen of evidence of servicing of equipment and a thorough maintenance schedule. Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 22 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 x x x x x x 1 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 3 2 3 Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 23 yes 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 OP1 Regulation 4&6 Requirement The Registered Person must add to their Statement of Purpose the number of service users they are registered for and provided evidence that the statements listed in this standard are taking place in the home. The Registered Person must add to their Service Users Guide a copy of their terms and conditions and contract. Service users, irrespective of how their care is paid for, must receive a copy of the homes terms and conditions. Timescale of the 1/8/04 was not met, however due to the merger with Southern Cross this has been put on hold. This will be completed once the company has reviewed their documentation. Timescale of the 01/07/05 was not met. The Registered Person must ensure that all service users have care plans for all identified problems. The Registered Person must obtain copies of the service users DS0000038272.V266404.R01.S.doc Timescale for action 01/04/06 2 OP1 5&6 01/04/06 3 OP2 5(1b & c) 01/05/06 4 OP7 15 01/03/06 5 OP8 15 28/02/06 Hygrove House Nursing Home Version 5.0 Page 24 6 OP12 16(n) 7 8 OP26 OP26 16(k) 12 4(a) & 23 13(3) 9 OP26 10 OP27 18(1a) 11 OP30 18(1c)(i) 12 OP37 17 & Schedule 4(13) ‘wound mapping’ and photographs as directed in their care plans to assist in the ongoing evaluation of the wounds. The Registered Person must provide activities suitable for the needs and interests of the service users. The Registered Person must ensure the home is kept free of offensive odours. The Registered Person must review the laundry arrangements to ensure they are meeting the needs of the service users. The laundry must be fitted with a continuous floor covering which can be adequately washed. Timescales of the 1/8/04, 1/2/05 and 01/07/05 was not met. The Registered Person must ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users. Timescale of the 17/05/05 was not met. The Registered Person must ensure that all staff receive training appropriate to the work they are to perform. The Registered Person must keep records of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. 01/03/06 28/02/06 01/03/06 01/03/06 20/02/06 01/05/06 01/03/06 Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 25 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 OP1 Good Practice Recommendations Where the home has mentioned in their Statement of Purpose and Service Users Guide that the staff have dementia training they should be more descriptive about what this training contains. Care plans should not have ambiguous statements in them, as these statements can be confusing to staff and there is no way to measure against these to see if they are happening when reviewing care plans. Care plans should document service users interests to assist with devising an activities programme. The home should find out if any service users are subject to the Care Programme Arrangements and if they are, obtain a copy of the plan. The staff completing assessments for the first time should date and sign them. The home should keep records of cleaning schedules for the kitchen and undertake a hazard analysis. 2 OP7 3 4 5 6 OP7 OP8 OP8 OP15 Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hygrove House Nursing Home DS0000038272.V266404.R01.S.doc Version 5.0 Page 27 - 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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