Inspection on 17/05/06 for Ingleby Care Home

This inspection was carried out on 17th May 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

Ingleby Care Home 22/09/09

Ingleby Care Home 26/03/09

Ingleby Care Home 25/03/08

Ingleby Care Home 18/05/07

Ingleby Care Home 19/09/05

Ingleby Care Home 16/05/05

Ingleby Care Home 22/09/04

Ingleby Care Home 15/06/04

Ingleby Care Home 27/02/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Ingleby Nursing Home Lamb Lane Ingleby Barwick Stockton-on-Tees TS17 0UP Lead Inspector Jackie Herring Key Unannounced Inspection 17th May 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 Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 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. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ingleby Nursing Home Address Lamb Lane Ingleby Barwick Stockton-on-Tees TS17 0UP 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) 01642 750909 01642 750966 T L Care Ltd Mrs Valerie Thomsen Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That a maximum number of 5 places may be used at any one time for the accommodation of persons who are 50 years and over with a physical disability. One named individual who is under the age category is allowed to reside in the home. One named individual who is under the age category is allowed to reside in the home for a period of respite care. 19th September 2005 Date of last inspection Brief Description of the Service: Ingleby Nursing Home is a 50 bedded purpose built care home, which provide personal and nursing care. All 50 rooms are single rooms with ensuite facilities and there is the required number of bathing facilities and communal space. Ingleby is owned by TL Care who also operate a further four homes in the Teesside area. Ingleby Nursing Home is close to the centre of Ingleby Barwick, being in easy reach of the local church, supermarket and parade of shops. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and was conducted in two inspection days, fourteen inspection hours in total. As a key inspection, all of the key standards were examined, which included an examination of residents records, social activity arrangements, medication records, a tour of the home, health and safety records, staff records and training and discussion with residents and staff. A pre inspection questionnaire was completed and six relative surveys and eight residents surveys were completed. Six residents were involved in discussion about life within Ingleby Nursing Home, staff were interviewed and there was also informal discussion. In direct observation also took place. This was a very good inspection in which it is clear that much progress has been made to improve and develop a number of areas within Ingleby Nursing Home. What the service does well: It is evident from the inspection that the Manager and staff at Ingleby Nursing Home are working hard to ensure that improvements are made to the home, and that residents are happy. Residents said, “The staff are very pleasant, nothing is a bother and we have respectful relationships”, “Very obliging, friendly staff who are very patient and understanding”, “I prefer to stay in my own room, however staff will pop in to see me”, “My care needs are being fully met”. “It is absolutely fine here, very obliging, friendly staff, do anything for you, always very kind, very patient and understanding girls”, “It is a very good home”, “There is no place like home, but I am being well looked after”. The resident’s surveys were all generally positive, comments included, “Staff very friendly and helpful. Feels safe and secure now, apprehensive at first but soon settled in”. Staff were very enthusiastic about their job roles and about life within Ingleby Nursing Home, one staff member said, “The home has improved since the new matron, getting more and better communication, have regular meetings and group discussions as issues arise”. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Whilst improvements have been made at Ingleby Nursing Home, particularly to the environment and residents records, it is acknowledged by the manager that there continues to be work to do. There is the need to build upon the assessment and care documentation to ensure that social and healthcare needs are identified and are being met by the home. There is also the need to include lifestyle preferences and a good history of the individual residents to ensure that care can be planned appropriately and that individual expectation and aspirations are met. The environments continues to need some further improvements to include the redecorating and replacement carpeting within the entrance to the home, the corridors and the dining rooms. It is disappointing that the peach bathroom on the ground floor remains out of use and has done so since 2004. The quality assurance systems also need to be developed further and the policies and procedures whilst in place were not up to date and had not been reviewed. Whilst mandatory training relating to health and safety is in place, not all staff are up to date with all components of it. It is acknowledged that steps are in place to address this. Medication policy and procedure were in need of updating and some of the systems needed to be developed further to ensure robustness of practise. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 7 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. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 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 Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 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 The statement of purpose is in need of updating to ensure residents have adequate information. Resident’s needs are adequately assessed prior to admission to the home, which ensure that the home is able to meet resident’s needs. EVIDENCE: The format of the statement of purpose continues to be in need of further development making is more accessible to residents. One of the standards was an outstanding requirement from the previous inspection. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 10 Four sets of resident’s records were examined all of which contained a copy of the pre admission assessment and where appropriate also a copy of the care management assessment. The pre-admission assessment contained appropriate information to demonstrate that Ingleby Nursing Home was a suitable care home for prospective residents. These could be enhanced further by including more detailed individual information. Ingleby Nursing Home does not provide Intermediate Care. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 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, 9, 10 Whilst care records are in place for the residents, the assessments, risk assessments and care plans need to be developed further and do not set out fully resident’s health, personal and social care needs. Residents spoken to have their privacy needs and rights upheld and are treated with dignity. The medication systems are in the main robust however some development is needed and the medication procedures do not adequately support the systems. EVIDENCE: Four sets of resident’s records were examined and there had been improvements since the last inspection in regard to the level of personal detail contained within some of the assessment documentation and there has been a move from pre prescribed care plans to resident specific care plans. There continues to be the need to further increase the level of personal detail, social needs and health care details within the assessment of need in all of the resident’s records. During discussion, it was agreed that the documentation itself was satisfactory if not overly burdensome and repetitive, which may deflect from detailing the appropriate information. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 12 It was also identified that the care management assessments which contained a lot of detailed and valuable information had not been used within the records at Ingleby Nursing Home and as such, all care needs had not been fully identified, risk assessed or care planned for. An example of this being, a resident with right sided weakness and who suffers from pain, there were no plans of care in place for these areas in which care, support and monitoring would be needed. Health needs assessments such as nutritional assessments and pressure risk assessments had not fully been completed in all of the records examined, as such, it was unclear if needs were being met. The resident’s records did not contain evidence that the assessments and plan of care had been discussed with individual residents or their relatives. Details for GP, District Nurse, Optician and CPN visits were detailed within all of the files examined. The medication systems were examined during the inspection and the storage, recording and administration of medications was in the main robust. There was one area in regard to the procedure for recording and administration of controlled drugs that needed to be reviewed. The Medication Administration Records were not well produced as such; in many cases the first letter was missing from the prescribed drug, which could lead to mistakes in administration. The procedures for the returns of nursing residents medication was not as robust as needed as there was no records detailing returned medication and the system for managing the unused controlled drugs for nursing residents was not in place. The actual policy and procedure for medication management within the home are in need of a full review and updating. Residents who were spoken to during the inspection said, “The staff are very pleasant, nothing is a bother and we have respectful relationships”, “Very obliging, friendly staff who are very patient and understanding”, “I prefer to stay in my own room, however staff will pop in to see me”, “My care needs are being fully met”. Staff talked about keyworker systems and attending monthly reviews with the residents. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 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, 13, 14, 15 Activities are in the main well managed for residents ensuring social, religious and recreational needs are provided for, these could be linked to a more detailed social and lifestyle assessment. Residents are able to control aspects of their lives, their independence and make choices. Meals are provided to a satisfactory standard within a suitable environment however further improvements could be made to improve yet further. EVIDENCE: Ingleby Nursing Home has an activities co-ordinator in post, however the manager did say that the actual recreational and activity programme was under review. Residents talked about opportunities for hobbies and interest and one gentleman spoke of going to play garden bowls a couple of times a week, going out for walks, visiting the local shop to purchase his newspaper etc. The records showed that there was no actual social assessment although preferences are recorded such as, “likes football”, “likes bingo”. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 14 On the second day of the inspection, there was a coffee morning taking place and it looked like everyone was enjoying the fresh home made scones. It was confirmed through discussion that there were church visitors to the home and that residents could and did visit the local church, which was very close to the home. It was also confirmed through discussion with residents that they received visitors and that they were could visit the home at any time. Some residents also visited their families at home. During discussion with residents they said that they were well able to make decisions and to take control over their daily lives. Residents said, “A friendly atmosphere, don’t have to be formal and I have my own routine”, “I pretty much please myself, I let the staff know when I am going out and I can do whatever I want”, “I am happy with my own privacy, I have my books and my crosswords and I like to be independent”, “I have my own telephone, I speak with my family every day and enjoy listening to Classic FM, am able to make my own decisions”. Meals were said to have improved since the last inspection, the inspectors observed the mealtime and meals were well presented on the plates. During discussion with residents they said, “Marvellous meals, plenty to eat”, “The meals are fine”. During discussion with a small number of residents over lunchtime they were generally satisfied with the choice, quality and variety of the meals. Some suggestions were made which residents thought would further improve the meals this included being able to have meals served on hot plates, for individual preferences to be taken more account of such as portion size and actual likes such as vegetables which tend to be put on everyone’s plate whether they like them or not and having a gravy boat on the table. The manager confirmed that plans were in place for the refurbishment and redecoration of the dining rooms. A two-week menu was included with the pre inspection questionnaire; it detailed traditional meals with a choice at both lunchtime and teatime. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 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, 17 Effective systems are in place for managing complaints. The residents are generally protected, however further staff training is needed to increase knowledge and awareness, as this is currently not adequate. EVIDENCE: Residents who were spoken to said they were confident in raising concerns if they needed to, they said, “If I had any concerns I would complain to the Matron, who is very kind”, “Raised concerns about the hairdressing room, this is being dealt with”, “If I had any concerns I would speak to the Matron, I had concerns about the shower, this was sorted out straight away”. A resident stated within one of the surveys, “I could make a complaint to the Matron or deputy or senior member of staff, they would all be sympathetic and listen and advise me”. The pre inspection questionnaire detailed that there had been seven complaints in the last twelve months, five of which were upheld. The complaints log was made available of examination and contained the required information. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 16 Staff who were spoken to said they were aware of the subject of abuse and of what to do in the event they saw or heard anything of concern. They confirmed that there was a poster in the staff nurse detailing No Secrets. The training records demonstrated that there was still a large number of staff that had not completed formal training on No Secrets, Protection of Vulnerable Adults. During discussion with the Operation Manager, she confirmed that they were in the process of contracting all of their training including No Secrets Training to an independent training organisation and that this training would be fully implemented in the near future. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 26 Ingleby Nursing Home provides a safe environment for the residents. The environment is adequate however it is in need of further improvement to make it a more comfortable and homely place for residents to live. EVIDENCE: Improvements have been made to the environment at Ingleby Nursing Home since the last inspection, with some decoration of communal areas and bathrooms and new carpets were in place in lounge areas. It was acknowledged by the manager that there is still much work to do and she confirmed that there were plans underway for this work. This included the redecoration and refurbishment of the entrance to the home, the corridors and dining room, all of which were somewhat tired looking this included the carpets. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 18 The peach bathroom on the ground floor continues to be in need of attention as the bath has now been out of use for several years. Improvements had been made to other bathrooms and shower rooms. On the first day of inspection the home was observed to be clean and was odour free, housekeeping staff were observed to be completing their duties and a safe manner. During discussion with the manager it was confirmed that plans were underway to improve the external environment at Ingleby Nursing Home, with a more accessible garden with patio area to be developed. Planned improvements are also going to be made to the conservatory, which will make it a more pleasing environment. Some improvements have been made to the bedroom furniture this however should continue as some continues to be in need of attention. It was noted on visiting a number of bedrooms that there continues to be no light shades over the fluorescents strip lighting in the ensuite facilities. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 19 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 The deployment and number and skill of staff on all shifts is appropriate to ensure that at all times residents are supported by an experienced, reasonably well trained team of staff. The procedures for the recruitment of staff are robust offering protection to residents. EVIDENCE: Many changes have taken place since the last inspection regarding the staff structure and skill mix of the staff team. Care staff have undergone substantial training to enable them to be appointed a senior care staff and to expand their role to assess, plan and care for residents with personal care needs and also to administer medication. Staff spoke very enthusiastically about their job roles and spoke positively about the changes made at Ingleby Nursing Home. Qualified staff also confirmed that the changes made have been a great improvement and that they now had more time to dedicate to the nursing residents within the home. During interviews with residents and staff they confirmed that there was sufficient staff on duty to meet individual needs. Staff of different grades were spoken to and were clear about their job roles, one staff member said, “there is loads of training”. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 20 Four staff files were examined during the inspection, two new staff and two randomly selected, all of which contained the required information such as application form, appropriate references and Criminal Records Bureau checks, all of these records were appropriate and in order. Training records have improved since the last inspection and the training matrix detailed the entire mandatory training as well as appraisal and No Secrets training. It did not detail and client specific training although staff did confirm that they had received additional training such as Dementia Care. Separate training files were also made available for examination. The training matrix also demonstrated that all staff had completed the required induction. The pre inspection questionnaire detailed that 52 of staff had completed NVQ Level 2. It was also confirmed that all staff responsible for the administration of medication were either qualified staff or were supervisors who had completed a course on the safe handling of medicines. During discussion with the Operation Manager, she confirmed that the organisation were in the process of contracting all of their training including all mandatory training as well as client specific such as diabetes care to an independent training organisation and that this training would be fully implemented in the near future. Staff confirmed that they would like some additional training included Diabetes and Parkinson’s Disease. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 21 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): 31, 33, 35, 36, 38 Ingleby Nursing Home is a well run and managed home with an experienced staff team. Quality assurance systems are in place and resident’s financial interests are safeguarded. Policies and procedure do not adequately ensure that the health and safety and welfare of resident are fully promoted and protected. EVIDENCE: The manager of the home is registered with CSCI and she is a Registered General Nurse who has the required qualifications and experience to manager Ingleby Nursing Home. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 22 Residents who were spoken to said, “It is absolutely fine here, very obliging, friendly staff, do anything for you, always very kind, very patient and understanding girls”, “It is a very good home”, “There is no place like home, but I am being well looked after”. Staff said, “The home has improved since the new matron, getting more and better communication, have regular meetings and group discussions as issues arise”. It was noted during the two inspection days that the actual atmosphere of the home had improved and was much more relaxed, staff were visibly happier in the home and there was a sense of openness. Quality assurance systems were discussed with the manager who said that some developments have been made in this area although there was still much to do. A food quality audit has been carried out and residents questionnaires have been completed however these had not been fully analysed as the analysis system is currently numerical rather that qualitative. Additional audits of the environment, care plans and medication take place however these were not detailed enough and were all completed on a single audit sheet. The manager was advised to include health and safety factors within the environmental audits to include checking of window limiters and bed rails. A selection of residents personal allowance records were examined, all were in order and contained the required information and supporting material such as receipts. The pre inspection questionnaire detailed that the servicing of equipment such as fire, electrical wiring, lifts and hoists had been undertaken and were up to date. A random sample of in house service records were examined and detailed that the fire alarm is tested weekly. It was however identified that there was the need to increase the frequency of fire drill as none had been carried out since August 2005. Policies and procedures were made available for examination with five randomly selected to look at, including adult protection, missing person, infection control, and medication. Of the five, four were in need of review and updating. A number of them were not dated and there was no evidence of review. The information contained within some of the procedures were not up to date and did not reflect current practise. The manager said that all of the policies and procedure were being reviewed and updated at head office, however this has been ongoing for some time. This was also discussed with the Operation Manager who confirmed that work had taken place and understood the importance of completing this and ensuring that all policies and procedure were up to date and available for use within the home. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 23 Staff training records demonstrated that arrangement are in place for staff to receive mandatory training such as moving and handling, health and safety and first aid, however a number of staff were not fully up to date with this training. The operations manager acknowledged that the training was not a robust as it should be and arrangements have to put into place to address this. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 2 2 X X 2 X 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 X 2 X 3 3 X 2 Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14 Requirement Timescale for action 31/08/06 2. OP8 15 3. OP9 13 4. OP18 13 The assessment of need documentation and plans of care must continue to developed and built upon to include more detailed information about individual residents needs, lifestyles and preferences. There must be evidence of residents or representatives involvement with individual assessments and plans of care. The health care assessment tools 31/08/06 must be fully completed and contain the appropriate information which informs plans of care ensuring care needs are being met by the relevant professionals involved. Developments must take place 31/08/06 to some of the management of medicines such as returns of medicines and controlled drugs. The policy and procedures must be updated and reflect current legislation and practice. Training on the protection of 31/08/06 vulnerable adults must continue and must be rolled out to all staff. DS0000055360.V291026.R01.S.doc Version 5.1 Ingleby Nursing Home Page 26 5. OP20 23 6. OP21 23 7. 8. OP24 OP30 16 18 9. OP33 24/26 The planned refurbishment programme must take place including the redecoration and replacement carpets within corridors and dining areas of the home. The peach bathroom on the ground floor must have the bath replaced. (This is an outstanding requirement since 22/09/04) The bedroom furniture must continue to replaced or refurbished. Further client specific training must be implemented and training records must to update to demonstrate this. The systems for monitoring quality within the home must be developed further and information must be analysed and made available to residents and relatives. 30/09/06 31/08/06 31/10/06 31/10/06 30/09/06 10. OP38 13/23 Reports from Regulation 26 visits must be forwarded to CSCI. All staff must have participated 31/08/06 in two fire drills per year. The policies and procedures must be reviewed and updated. Staff must be up to date with all mandatory training. 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 OP2 Good Practice Recommendations The format for the Statement of Purpose continues to be DS0000055360.V291026.R01.S.doc Version 5.1 Page 27 Ingleby Nursing Home 2. 3. 4. OP3 OP12 OP15 in need of further development, making it more accessible to the residents. The pre admission assessment could be enhanced further with more individual and detailed information. The recreation/social activities programme should be developed in accordance with detailed social and lifestyle assessments. The meals provision should be reviewed to ensure that individual preferences are taken account of. It is recommended that consideration be given to providing food on hot plates and that gravy boats are put out on the dining tables so residents can help themselves. Ingleby Nursing Home DS0000055360.V291026.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. 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