Inspection on 15/11/07 for Island Court Nursing Home

This inspection was carried out on 15th November 2007.

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

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

Other inspections for this house

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Heathlands

Aston Court Nursing Home

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE Island Court Nursing Home Bourne Street Woodsetton Sedgley West Midlands WV14 9HN Lead Inspector Mandy Beck Unannounced Inspection 15th November 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Island Court Nursing Home DS0000070840.V358585.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. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Island Court Nursing Home Address Bourne Street Woodsetton Sedgley West Midlands WV14 9HN 01902 886300 01902 886359 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) Select Health Care Ltd Susan Geary-Campbell Care Home 55 Category(ies) of Old age, not falling within any other category registration, with number (55) of places Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Manager to be supernumery for four days per week. 31 older people who may have a physical disability and require nursing care will be accommodated on the ground floor. 24 older people who may have a physical disability and require personal care only will be accommodated on the first floor. 26th October 2006 Date of last inspection Brief Description of the Service: Island Court is a purpose built care home providing nursing and personal care to a maximum of 54 residents’ age 65 years and above. The ground floor accommodates residents’ requiring nursing care, the first floor accommodates those requiring personal care. The home is situated a mile and a half from Sedgley town centre. It is on an easily accessible public transport route to local areas, Dudley and Wolverhampton. The home has an experienced manager. A deputy manager is responsible for managing care of residents’ and supervising staff on the first floor. Registered Nurses provide nursing care to those residents’ who require this service. The home provides single bedrooms only. Each bedroom has an en-suite consisting of a toilet, hand wash basin and shower. Sufficient lounges, dining areas, bathrooms and toilets are available within in the home. The home has a fully equipped hairdressing salon on the first floor. The homes fees for residency are not included in the Service User Guide. Fees do not include extra services such as hairdressing, chiropody, dentist and newspapers. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection completed in one day by one inspector. The home completed their Annual Quality Assurance Assessment (AQAA) requested by the Commission for Social Care Inspection (CSCI), we have used information from the AQAA in the body of the report to support some of the judgements. Other evidence was supplied by the home manager, by touring the premises, and by talking to staff and the people who live there. Service users and their relatives were also invited to provide comments on the home by completing postal surveys. Service users files were viewed as part of the case tracking process, this means looking at their assessment details, care planning and how the home involves people in this process. Staff files were examined to ensure the home is continuing to recruit workers safely and that required staff training is also being carried out. The inspector would like to thank all of the staff and service users at Island Court for their hospitality throughout the day. What the service does well: The home is pleasantly decorated and provides a relaxing atmosphere for people to live in. Service users told us “the housekeeping staff do an excellent job” and “it is very clean”. Each person has their own individual plan of care that details their care needs. All new service users are assessed on admission so that potential risks such a pressure sore development, falls and moving and handlings issues can be addressed promptly. There are dedicated activity coordinators for the home who ensure that people are engaged in activities throughout the day. People said “we have our hair done every week, we exercise regularly, play dominoes and cards. I enjoyed very much enjoyed the trip to the garden centre” Meals are freshly prepared on the premises and there are good choices available to all service users, the home is able to meet specific dietary needs of all service users, meal times are a relaxing time and service users commented how much they enjoyed the food. “there’s always a choice, the food is lovely”. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 6 The home responds positively to complaints and service users stated that if they were unhappy they were confident that there concerns would be acted on promptly. “I have no worries about complaint reporting” Staff receive regular training and support from the management team to make sure that they are always providing care that is based upon current best practice. There are enough staff on duty to meet the needs of the people who live there. One person said “all the staff at Island Court are excellent and perform well above the call of duty”. Medication practices within the home have improved and all staff have now received accredited training. The home has streamlined its medicine provision and now has all of its medicines from one pharmacist. What has improved since the last inspection? What they could do better: The home consults regularly with the people that live there and their families, they have many consent forms in each person files. It is recommended that all of these consent forms are reviewed to ensure that they still represent the wishes of service users. The home must also be clear when making decisions for people that they have done so in their best interests. It is also recommended that all staff receive training on the Mental Capacity Act 2005. This will help staff to understand their roles and accountability when supporting people living in the home. When we looked at some people’s bedrooms we noticed that bed rails were not adequately fitted and posed a risk to the health and safety of service users. We wrote to the home asking them to take urgent action to rectify this situation. It is pleasing that they have taken action and have ordered 12 pairs of new bed rails for service users comfort and increased safety. The manager must now make sure that all people who have bed rails in their beds have an up to date risk assessment and regular maintenance checks take place. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 7 We have also recommended that action be taken to reduce the temperature in the treatment room on the ground floor. The temperature regularly exceeds the recommended 25oC and must be addressed so that service user’s medication is being stored within recommended guidelines. This concern was raised during the previous inspection and is still outstanding. 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. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 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 Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 Quality in this outcome area is good. All people who choose to live in this home can be sure they will have enough information to make a decision about living here. Their needs will be assessed in full before they move in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All prospective service users are assessed by the manager of the home, she will meet with people in their own homes or in hospital if needed. The assessment tool contains all the relevant information that means people’s needs will be identified and allows the manager to make a judgment about whether the home can meet those needs. Wherever possible service users and their families are encouraged to spend time at Island Court before making the decision about moving in on a permanent basis. This can take the form of spending a whole day at the home or just staying for lunch. Relatives are welcomed at anytime to view the home should the service user be unable to do this. It is recommended that all staff be given further training in completing Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 10 the new assessment documentation that has recently been introduced. Some of the staff said that they found it confusing and didn’t understand all of the sections fully. Once the decision has been made the manager will write to service users confirming that the home feels it can meet their needs. Each person will have a contract and terms and conditions of residency. Concerns were raised by some families about recent changes to the contract that required them to pay 50 of the hire cost for some equipment. They felt that this was unfair and were worried that their relative may not receive the care they needed if they were unable to pay the required 50 hire cost. This was discussed with the manager during the inspection she said that the organisation (Select Healthcare) had reviewed this clause and had taken the decision to remove it from the contract. Service users will be issued with new contracts in the near future showing this change. Staff at the home are skilled and knowledgeable, there are trained nurses and care staff who are on site to meet service users needs. Their skills are kept up to date with regular training sessions The home does not provide intermediate care services. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. People who live in this home can feel confident that their healthcare and personal needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each of the service users files we looked at showed detailed care plans that had been rewritten and were more person centred than in previous inspections. The home has worked hard to improve upon their person centred care planning for each person. It is possible to gain a full understanding of each person needs when reading through the care plans. Each person also has a key worker assigned to them, the details are in each person’s bedroom. Key workers are there to support service users and give them an identified person to relate to if things aren’t right for them. All service users are assessed for their risk of developing pressure sores, falls and moving and handling. It was pleasing to see that of those people who Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 12 were at high risk of developing pressure sores they had all of the necessary equipment to help reduce the risk of pressure sores developing. Some service users need bed rails to keep them safe whilst in bed. It was noted that some of the bed rails on their beds posed a risk to their health and safety because they were incorrectly fitted. This was immediately bought to the manager’s attention. The home was asked to take urgent action to reduce the risk to service users. It was pleasing to see that the following day the home had ordered twelve new pairs of bed rails and were putting in place new measures to make sure that bed rails will be sufficiently maintained in future. the manager must also make sure that each service user who requires bed rails has their own bedrail risk assessment in place, this must be kept under regular review. All service users have regular access to their own doctor’s, district nursing service, where appropriate and other healthcare professionals such as the Speech and Language therapist and the Stroke team. The home has said that they intend to increase the number of visits the chiropodist makes to the home so that service users can benefit from increased visits and more frequent treatment. Service users told us “the doctor is called immediately if needed or at least the following day”. Medication practices within the home have improved since the last inspection. The manager confirmed that all of the staff who administer medication on the first floor have completed their accredited training. Medicines are stored safely but not always at the correct temperatures, the manager must take steps to reduce the temperature in the ground floor medication room if it continues to go above the recommended 25 oC. This was recommended at the last inspection and continues to be a problem. Records of all medicines received into the home are kept and there are safe systems in place for the returns of all unused medication. There were some minor areas for improvement such as staff using ticks on the Medication Administration Record (MAR) sheet to indicate administration of creams and there were also a few gaps on the MAR sheet. The person who has administered the medication must sign each administration and there must be no gaps on the MAR sheet every omission must be accounted for. Controlled medication is administered safely on both floors and records for administration were satisfactory. All of the service users agreed that the staff treat them with dignity and respect their privacy at all times. One service user commented “the staff are very good at listening and acting upon our requests”. Staff were observed talking to service users politely and were seen to be knocking doors before entering. One relative said “I am very impressed with the care and support given to my mother”. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 13 Of the service user files seen some of them had details of their end of life care. The manager said that she has a copy of the Gold Framework for End of Life Care and is planning to implement this in the near future. This will mean that people will have the opportunity to plan their end of life care and the home will be able to make arrangements to meet their needs when the time comes. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. People who live in this home are supported to live an active life. The food provided is of a good quality and enjoyed by the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the service users spoken to during the inspection said that the staff try their best to keep them occupied during the day. There are always planned activities on offer and the home employs its own activity coordinators who work with the service users planning activities. Recent events have included pub outings, fish and chip suppers and making festive decoration for Halloween. A trip to Walsall Illuminations was being planned in the near future. During the inspection we sat in a reminiscence group conducted by the activity person. It was fun and gave all of the people taking part an opportunity to talk about things they remembered and also to talk to one another. Service users told us “we have our hair done every week, we exercise regularly, play dominoes and cards. I very much enjoyed the trip to the garden centre”. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 15 Service users are actively involved in their environment and work with the manager to ensure that all of the events the home organises are based around the wishes of the service users. Family and friends are made to feel welcome and they know that they can visit the home at anytime. There are plenty of communal areas throughout the home where service users can entertain their visitors including their own rooms. Service users are encouraged to bring in personal items to ensure that their rooms are made to feel more homely and comfortable for them with familiar items. Wherever possible service users are encouraged to manage their own finances and make decisions about their lives. The home provides details for service users about advocacy services who may help them if they require the service of independent people. We also recommended that staff receive training about the Mental Capacity Act 2005 this would give staff an understanding of their roles and accountabilities to the people in the home when they are supporting them to make decisions and choices about their care. The home has consulted with some service users and their families about consent to different aspects of their care and treatment. It is strongly recommended that the consent forms are kept under regular review to make sure that they continue to represent the wishes of service users. Meals are wholesome and appetising, service users were very pleased with the meals on the day of the inspection commenting “the food smells good but tastes better”, “there’s always a choice”, “good food choices”. The dining rooms on both floors have been redecorated and they are now a relaxing place for service users to eat and drink. On the ground floor there is a “two sitting” plan in progress that means that the service users who require assistance with eating and drinking receive their meals first this enables staff to spend more time with them and ensure that they get the assistance they need at the right time. This idea was discussed at a recent residents meeting and has proved to be popular. We were able to sit with service users during mealtime and ate lunch which was very tasty and very hot. Menu’s are supplied daily and are on display on the dining tables for service users to read, there are always two choices available and in addition a vegetarian menu. Special dietary requirements are also catered for. Island Court Nursing Home DS0000070840.V358585.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 Quality in this outcome area is good. People who live in this home can feel confident that their concerns will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has complaints policy that shows how the home will investigate any complaints. The complaints procedure is available in all of the service user bedrooms. All of the service users stated that they knew who to make a complaint to if it was needed. We have received one telephone call expressing concerns about the new contract and cost of equipment hire. This was discussed during the inspection and the manager said that this clause will no longer be relevant and will be removed from contracts in the future. Service users will be given new amended contracts in the near future. The policy and procedures in the home for the protection of vulnerable adults are updated and reviewed regularly. Most of the staff have received training in adult protection this is a big improvement on the last inspection. Service users can feel confident that the home is now able to keep them safe from harm and that staff will act appropriately when allegations are made. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 17 Island Court Nursing Home DS0000070840.V358585.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): 19,26 Quality in this outcome area is good. People who live in this home live in a well maintained clean environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has been redecorated throughout and is now very bright and clean throughout. The manager has told us that a housekeeper has now been employed and has proved to be a big asset to the home. In addition to this all of the service users bedrooms have been redecorated and some refurbished. All new service users will have their bedrooms decorated prior to their admission this will help them feel more at ease when they move in if the room is decorated to their taste. People told us “the housekeeping staff do an excellent job”, “it is very clean”, another person said “I don’t like the laminate flooring in my room its very noisy and shows every mark and stain and its certainly not homely”. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 19 The laundry was viewed the laundry floor has been recoated however this will need to be done on a regular basis to ensure that it remains intact. The home provides liquid soap and paper towels for service users to use again to reduce the risk of spreading infection. Staff are continuing with their infection control training once all staff have completed this it will further compliment the homes infection control practices. The manager also told us that there are plans to extend the home with four new bedrooms, a new laundry, treatment room and a conservatory. These additions to the home will offer more space in the home. Island Court Nursing Home DS0000070840.V358585.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 Quality in this outcome area is good. People who live in this home are supported by staff who are able to meet their needs and supplied in sufficient numbers to do so. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff are employed in sufficient numbers to meet the needs of the people living in this home. The home provides nursing care to people on the ground floor; this is staffed with registered nurses and care assistants. The first floor is a residential unit and does not have registered nurses on duty but is staffed with a deputy manager and senior care assistants. People told us “sometimes staff shortages can be a problem”. “Staff are extremely responsive and take requests on board they treat everyone as individuals”, “at certain times of the day they are very stretched such as mealtimes”, “good caring staff have been lost because they cannot live on the wages they earn”. “All the staff at Island Court are excellent and perform well above the call of duty”. “Staff are willing to help and are very approachable”. The home has made excellent progress with it’s care staff obtaining their NVQ level 2 in care and currently 31 of the 40 of care staff are qualified to this level and a further 5 staff are in the process of completing it. The manager is also arranging other training days that include “care of the person who has had a stroke”, “dementia awareness days” and risk assessment training. Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 21 Recruitment practices are good and safeguard service users. Staff files were seen and all contained the relevant checks from PoVA and CRB disclosures. Since the last inspection the manager has spent a lot of time making sure that staff files contain all required information as previously there had been shortfalls. It was pleasing to see that staff files are well organised and up to date, holding all relevant information. Once an employee has started working at the home they are expected to complete an induction programme, since the last inspection the home has introduced a more comprehensive programme that is now in line with the Skills for Care Induction standards. Staff receive regular supervision with the manager or senior worker on at least a bi monthly basis, this gives both the employee and the manager time to reflect on their practice and to be able to discuss work related issues and identify training needs to ensure that all employees continue to possess the skills required when looking after service users. Island Court Nursing Home DS0000070840.V358585.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 Quality in this outcome area is good. People live in a well managed, well run home. They can be sure that they will be consulted about how the can be run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is run by a manager fit to be in charge. All of the people who were spoken to agreed that “Sue” is wonderful and will help them at any time. They said “matron and her staff always put the residents first as it should be”, “matron is caring and will always help us to make things better”. The home continues developing its quality assurance systems steadily and should be commended on their hard work in this area. Service users are consulted regarding their care, the environment they live in and any other Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 23 changes that may affect them. The home now produces newsletters that keep service users and visitors informed of the changes happening in the home. the results of service users surveys are also included in the newsletter. The latest newsletter included details of changes to the menus as suggested by service users, more activities were needed and more have been arranged. The newsletter also includes information about new staff who have begun work at the home so that all service users are aware of this. Service users monies are held by the home in a secure location. Service users can be assured that the money the home holds for them is safe and secure at all times. Service users can have access to their money when they wish. There are satisfactory policies in place to further safeguard service users. All of the monies checked during inspection were correct and had receipts for all transactions, service users do sign to show that they have received their money. Safe working practices within the home are good, there are now systems in place to ensure that staff are receiving regular mandatory training to keep their skills updated and knowledge of health and safety current. Safety certificates were spot checked and found to be in order. The home also has good systems in place for ensuring that all staff have regular training in health and safety, food hygiene, first aid and fire safety. Island Court Nursing Home DS0000070840.V358585.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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 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 OP9 Regulation 13(2) Requirement Timescale for action 30/12/07 2 OP38 13(4) The temperature in the treatment room on the ground floor must not exceed 25oc at anytime. Service users medication must be stored within the recommended guidelines to ensure that it is not adversely affected. People who need bedrails for 16/11/07 their own safety must have risk assessments that are regularly reviewed. Their bed rails must be fitted in line with manufacturers guidance and be regularly maintained. Urgent action letter dated 16/11/07 Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 26 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 2 Refer to Standard OP1 OP4 Good Practice Recommendations It is recommended that the statement of purpose and service user guide be updated to include the range of fees the home charges for residency. All staff should be given training on how to use the new assessment paperwork to make sure that they are clear about how to use it and service users needs are recorded accurately Staff should receive training in Mental Capacity Act 2005 so that they understand their roles and responsibilities to service users under this act. 3 OP14 Island Court Nursing Home DS0000070840.V358585.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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