CARE HOMES FOR OLDER PEOPLE
Ivy House Nursing Home Hollin Wood Close Moorhead Lane Shipley West Yorkshire BD18 4LG Lead Inspector
Karen Westhead Unannounced Inspection 14th December 2005 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 Ivy House Nursing Home DS0000042291.V280655.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. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ivy House Nursing Home Address Hollin Wood Close Moorhead Lane Shipley West Yorkshire BD18 4LG 01274 591476 01274 591477 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) Holberry Care Ltd Mr Patrick Berry Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (15) Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. See below 1. Service users remaining in the home that fall under the category of older people will be named individually in separate covering letters of registration. As these service users die or move from the home they will be removed from the registration certificate and a new certificate will be issued. This process to continue until none of these service users remain in the home. It has been agreed that no charges will be made when new certificates are issued as part of this process. 20th January 2005 Date of last inspection Brief Description of the Service: Ivy House is a detached Victorian property, which has been converted and extended to provide the care home it is today. The home is registered to provide care, with nursing, for up to forty residents of both genders. The accommodation provides thirty-two single bedrooms and four double rooms. There are a number communal areas, including lounges, dining area and bathrooms. The home is in a quiet residential area close to the village of Saltaire. The gardens and patio areas are well maintained and are accessible to residents. The main entrance has a ramp and there is ample car parking to the side and front of the home. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that twelve-month period, the Commission for Social Care Inspection (CSCI) is required to undertake a minimum of two inspections of all care homes. This was the first inspection of this home for the 2005/2006 inspection year. This inspection was unannounced and was undertaken by one inspector. The visit started at 9.00am and finished at 3.45pm. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. The last inspection of this service was on 20th January 2005. At that time there were twelve requirements and five recommendations. Work has been done to address all the requirements and the manager confirmed that these had all been fulfilled. Three recommendations have been completed, the remaining two, which involve the recording of accident outcomes and the supervision of staff, have been partially completed. During the course of the visit, the inspector spent a large proportion of time speaking with residents, staff members and visitors. At the time of the visit the home had full occupancy. Those standards which were not assessed at this visit will be examined at the next inspection. A number of documents were inspected; some areas of the home were seen, such as bedrooms and communal areas. Most of the staff on duty were spoken to and observed carrying out their work. Individual and group discussions were held with residents and visitors. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. After completion these are returned to the CSCI. At the time of writing this report no comments cards had been returned. What the service does well:
An activity organiser, with the support of the manager and staff ensure that regular and meaningful activities are available for residents. There is level access to the garden and patio areas. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 6 Staff and visitors said Ivy House is a good home with warm relationships between residents and staff. This was evident during the visit. The home is busy, however, staff have time to spend with residents and visitors. Staff were described as ‘kind and patient’. Several of the staff on duty displayed their understanding and skills whilst working with those with visual, physical and mental impairments. Visitors commented on the cleanliness and good odour control in the home. They also shared their experiences of visiting and the delivery of care to their relative. One said ‘they do not talk to my wife as if she is a child, she is treated with respect and kindness.’ Another visitor said their relative had transferred from another home and that the care provided at Ivy House was superior and that the food was better and that their relative was given time to enjoy her meal without fuss. They went on to say that the carers were ‘polite and nothing was too much trouble’. Ivy House has a relaxed and homely atmosphere. The privacy and dignity of residents is respected. The ‘Friends of Ivy House’ meet on a monthly basis to discuss the running of the home and plans for the future. What has improved since the last inspection?
There has been a significant amount of work and progress made since the last visit in January 2005. The statement of purpose and service user guide have been reviewed. According to the manager, the format has remained unchanged. This was not read in depth but appeared to be a factual and informative document providing sufficient information for the reader to gain an insight into what Ivy House provided. A random selection of care plans were examined. Each contained an assessment of the residents needs with specific details about their health, personal care and recreational requirements. The manager has introduced a system where two care plans are reviewed daily at the main handover between shifts. This is an opportunity for the care plan to be evaluated, up dated and reviewed. The manager and senior staff team are proactive in involving other professionals when advice or assistance is required with the writing or setting up of the care programme. Written evidence of new documentation such as body mapping, fluid and food intake sheets, repositioning charts and pressure area assessments and risk assessment forms were seen in care plans. Ivy House has been involved in a multidisciplinary strategy meeting with the adult protection team in Bradford to make sure the residents who are at risk of developing or have pressure sores are receiving appropriate care. As a result of this an action plan was put in place. Since the meeting in November the
Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 7 home has a named link nurse who has the responsibility of working with the tissue viability nurse and overseeing procedures in the home. The medication policy has been rewritten. The requirements of the fire safety officer’s report have been addressed. A maintenance file has been compiled to log any regular work required in the home and when this has been done. For those staff whose first language is not English have been attending college to improve their communication skills. The manager is on schedule to complete his training before the timescale set at the last inspection. Due to the amount of paperwork and documentation required the manager is seriously considering installing a computer software package. The need to archive information, retain key documents and appropriate access for staff are all issues, which need to be considered. The community dietician visits residents if there are any identified difficulties. The contact continues. What they could do better:
The safety of the environment is given a high priority by the staff; however a number of requirements were highlighted. This involved the carpet in one bedroom which must be monitored to ensure it does not become a potential trip hazard, one bedroom had an unpleasant odour, the door to the sluice was found unlocked and checks must to be made to ensure all window restrictors are in place and in a good state of repair. The call system can be cancelled without staff visiting the activation point. Staff must remain diligent in this area and respond to all bells by visiting the call point. There was no evidence found on the day of the visit to suggest this was not being done. Staff must ensure the security measures in place are checked regularly so that residents cannot leave the premises without them knowing. Staff are waiting for new signage to be delivered to give visual prompts to those with limited capacity or literacy skills. Staff must record the outcome of any accident or incident. Staff should find alternative ways of monitoring weight loss or gain of residents who are non compliant when being weighed. All footplates must be used correctly when wheelchairs are in use.
Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 8 The residents, staff and visitors safety is compromised because fire safety equipment is not routinely checked on a regular basis. The fire alarm system must be manually checked on a weekly basis and a record kept of the date, time and outcome. 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. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 9 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 Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 10 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, 4 and 6 The statement of purpose and residents guide have been reviewed and are made available to interested parties. The admissions procedure is clear and caters for a range of different scenarios. Assessments are carried out before admission and sufficient information is gathered together to ensure the home can meet each individual needs. Residents admitted for rehabilitation into intermediate beds are helped to regain their independence and wherever possible return to the community. EVIDENCE: The statement of purpose is reviewed regularly by the management team and amended as required. At the point of admission, further leaflets and documents are provided if appropriate. Information is provided to prospective residents if appropriate or their relative/representative prior to them visiting, thus enabling them to make an informed decision about their stay. Information is presented in both written and pictorial formats.
Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 11 The inspector saw a number of care plans, chosen at random. All contained a pre-admission assessment. The manager confirmed that all residents are admitted on a trial basis. The trial period is set according to individual circumstances and an element of flexibility is built in to allow each resident time to ‘settle-in’. This is particularly relevant bearing in mind the abilities, insight and limited capacity of some of the residents. The inspector took the opportunity to talk to three sets of visitors. They each said they felt the admission process had been conducted in a logical and straightforward manner. They each said they had not felt pressurised to make up their minds. One relative said the trial period was extended to make sure their relative had had sufficient experience of the home before a decision was made about them staying. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 12 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, 10 and 11 Residents have a clearly written care plan which includes all aspects of their health and wellbeing. The non-compliance of residents does cause some difficulties for staff when collecting base line information such as weight loss and gain. Staff should look at alternative ways of working with residents where possible. Residents are treated with respect and their privacy is upheld. The manager confirmed that the medication policy had been reviewed. This was not assessed in detail during this visit. There is clear information for staff to follow in the event of a death in the home. EVIDENCE: Care plans have been improved and now give clearer information about the needs of each resident and how the needs are to be met. The manager has introduced a system where two care plans are reviewed daily at the main handover between shifts. This is an opportunity for the care plan to be
Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 13 evaluated, up dated and reviewed. The manager and senior staff team are proactive in involving other professionals when advice or assistance is required with the writing or setting up of the care programme. Written evidence of new documentation such as body mapping, fluid and food intake sheets, repositioning charts and pressure area assessments and risk assessment forms were seen in care plans. The environment allows for privacy and dignity for residents who are ill, being nursed in bed or are in the final stages of their lives. Relatives are asked about the final wishes of residents if they are unable to provide an account for themselves. This is documented on file. The manager confirmed that the pressure area care policy had been revised following the last inspection. There was evidence to support the significant input provided by the tissue viability nurse. Staff had also been carrying out their own research on the Internet and were using good practice guidance produced both nationally and locally. The manager had identified a nurse within the staff team to be the nominated as the link nurse. Her responsibility is to oversee all practice within the home, which relates to skin and pressure area care. Ivy House has been involved in a multidisciplinary strategy meeting with the adult protection team in Bradford to make sure the residents who are at risk of developing or have pressure sores are receiving appropriate care. Documentation relating to residents with pressure sores is now audited by the senior staff team. Daily records held were cross-referenced with other supplementary information. It was evident that staff had taken appropriate action when any changes in a residents skin condition; ability to mobilise; food/fluid intake and health needs had occurred. The manager said he had been liaising with doctors who look after residents at Ivy House and had been able to agree a strategy when urgent medication or dressings were needed in these instances. During a tour of the building it was evident that pressure-relieving equipment is in use. Links with continence advisors and other professionals are good. The manager and staff team have a positive working relationship with other agencies and reported they received a good level of support for residents. All residents have a nutritional assessment tool. These were not examined thoroughly during this visit, however they were referred to by staff in discussion. Staff did say that some residents were not compliant when being weighed or having their personal needs met. Some records of weight were well out of date and did not give any information about weight loss or gain. A record of why a weight has not been recorded should be made. Alternative
Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 14 methods should be explored to allow staff to monitor this as accurately as possible. It is acknowledged however that this is a difficult area. Records confirmed that residents have access to GP’s, opticians, dentists and chiropodists. On the day of the visit one resident was being seen by the community dentist. The inspector discussed one particular resident with the manager. The resident was displaying a diverse range of behaviours and finding it difficult to sit comfortably in the lounge area. The manager and staff team were able to demonstrate the input they had already had from a range of professionals. They were in the process of involving the occupational therapist. It was positive to note that the next of kin had also been involved in the care plan and had been able to add their support to the work being done. The inspector was told that if a resident is prone to falling the falls prevention team is used to provide advice and if necessary the care plan is adjusted. Staff must record the outcome of any accident or incident. From the existing staff team, five staff have had training on the completion and maintenance of care plans. All footplates must be used correctly when wheelchairs are in use. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 15 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 and 14 Residents are supported to use the accommodation as they wish. They are accompanied if they go out of the home and into the community. Regular group activities are provided, however, one to one time is also seen as a crucial part of resident care. Visitors spoken to said they are pleased with the care in the home. Relatives said they felt supported in maintaining contact with residents. Residents are given opportunities to exercise choice in an appropriate way, which matches their level of understanding. EVIDENCE: Ivy House employs an activity organiser who works in the home three afternoons a week. At other times staff on duty provide any recreational opportunities and carry on the programmes in place. The activity organiser completes a full assessment of each resident, which details their preferences, and any historical information given by relatives, which may give an indication of past hobbies or interests. It was evident that some activities had been modified to allow all residents the opportunity irrespective of their individual skills, concentration levels and abilities. There is an expectation that staff complete a daily record whenever a resident is engaged and to what level.
Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 16 Some gaps were noted, however, this should not detract from the good level of input given to social needs. Residents can access the garden but must be accompanied by a visitor or member of staff. A relatives group, the ‘Friends of Ivy House’ meet on a monthly basis to discuss the running of the home and plans for the future. They also raise funds. Contributions to the home have so far included a large screen projector, equipment which transmits sports programmes and films, which are shown regularly. Discussion points from the meetings are recorded. It is clear that the group are the ‘voice of the residents’ and has had a significant impact on the home. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 17 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 and 18 The level of staff understanding around the homes complaints procedure and adult protection shows that complaints will be taken seriously and residents will be protected from abuse. Visitors displayed confidence in the manager that any concerns would be investigated and acted upon. EVIDENCE: At the time of the visit there were no unresolved complaints. From discussions with staff it was clear that they have a good understanding of the different forms that abuse may take. There is an on-call arrangement if an incident should arise out of hours. All staff have attended a course on adult protection and the home has a clear written policy. Ivy House has been involved in a multidisciplinary strategy meeting with the adult protection team in Bradford to make sure the residents who are at risk of developing or have pressure sores are receiving appropriate care. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 and 26 The home is clean and provides a comfortable and homely environment for residents. However, some requirements were highlighted which are itemised below. Work has been done to address the fire safety requirements highlighted by the fire officer last year. A maintenance file has been set up which shows work carried out and that which is outstanding. Health and safety checks are carried out regularly. EVIDENCE: On the whole the premises were found to be satisfactory. However, the carpet in one bedroom must be monitored for a potential trip hazard, one bedroom had an unpleasant odour, the door to the sluice must be kept locked when not being used and checks must to be made to ensure all window restrictors are in place and in a good state of repair. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 19 The call system can be cancelled without staff visiting the activation point. Staff must remain diligent in this area and respond to all bells by visiting the call point. There was no evidence found on the day of the visit to suggest this was not being done. Staff must ensure the security measures in place are checked regularly so that residents cannot leave the premises without them knowing. Staff are waiting for new signage to be delivered to give visual prompts to those with limited capacity or literacy skills. The provision of a hatch, to serve meals and drinks directly from the kitchen has been well received by staff and residents. Some work was required to make good the area where this had been fitted, however this was in hand. Staff were finding that residents were able to leave the home, through the front door, when visitors had left, as there was a delay in the digital security system. This has now been rectified. Staff reported that all external doors were fitted with an alarm or a security device to alert staff if they were opened by a resident. During the visit one resident was seen to leave the building without being noticed by staff or an alarm sounding. The inspector informed staff to ensure the residents safety. A fault had occurred on the system. This must be regularly checked so as not to compromise the welfare of residents. All laundry is dealt with in house and appears to be handled appropriately. There are designated staff to deal with this task. Linen stores were found to be well stocked. One relative did remark about the loss of the occasional item of clothing but there did not appear to be a major problem with this. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The numbers and skill mix of staff were sufficient to meet the needs of residents. Staff on duty were able to demonstrate a good knowledge of the resident group and there is good teamwork. EVIDENCE: Visitors referred to staff in a positive way. They described the way they delivered care and showed patience and tolerance towards their relatives. The staff team includes nurses and carers and a team of ancillary staff. The team is managed by the registered owner who is also the manager. The number of staff on each shift, both during the day and night is adequate for the number of residents currently being cared for. A number of staff have worked at the home for a substantial number of years. One nurse has worked at Ivy House for over thirteen years and was employed before the current owners took over eight years ago. Three other staff have worked at the home in excess of nine years each. Staff training is on going and a number of one-day courses were advertised on the staff notice board. Several staff had signed up for attendance. Nine staff have qualified to National Vocational Qualification Level 2 and three to Level 3.
Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 21 Courses already attended in the last six months have included food hygiene, palliative care, adult protection, wound and skin care and infection control. All new staff receive induction training. The manager employs a number of staff whose first language is not English. They have been attending a course at a local college to improve their written and spoken English. One member of staff was said by the manager to be finding the course harder than the others but support had been offered and they were always on shift with staff who could assist where necessary. It is worth noting that the diversity in languages spoken is of benefit to some residents who also speak a different language. The manager said he was on schedule to complete his professional training before 30th June 2006, which is the timescale set at the previous inspection. Staff on duty said the team works well together. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The manager and senior staff team continue to make positive changes to improve the quality of care and provide the leadership needed for the home to run in the best interests of the residents. The management approach encourages relatives to be involved in the day-today running of the home. EVIDENCE: During discussions with relatives and staff it was felt that the manager is approachable and particularly supportive to staff. Staff said they enjoyed their work. The manager gave a frank and honest account of his management style and prides himself in the fact he is an active manager. His enthusiasm for providing a good level of care is echoed in the attitudes of the staff spoken with during the visit. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 23 There are systems in place to enable residents’ relatives to express their views about the home. The manager was in the process of ensuring all staff had received appropriate supervision and this involved checking supervision timetables and staff attention to this. Visitors and residents spoke of the kindness shown by staff and gave examples of good practice. Ivy House Nursing Home DS0000042291.V280655.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 3 X 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X X X X 2 STAFFING Standard No Score 27 3 28 3 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 Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP8 Regulation 13(5) Requirement The registered person must make sure wheelchairs are used properly and that footplates are in position. The registered person must make sure security equipment is working effectively so that resident safety is not compromised. The carpet in one bedroom (identified) is showing evidence of wear and tear. This must be monitored to make sure it does not become a trip hazard. If it does a replacement carpet must be provided. The registered person must make sure the sluice room door is kept locked. The registered person must make sure appropriate restrictors are fitted to all windows and are in full working order. The registered person must make sure cleaning schedules are in place to eliminate
DS0000042291.V280655.R01.S.doc Timescale for action 30/03/06 2 OP19 13 and 16 30/03/06 3 OP20 13 30/03/06 4 OP26 23 30/03/06 Ivy House Nursing Home Version 5.1 Page 26 unpleasant odours. 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 3 Refer to Standard OP14 OP38 OP8 Good Practice Recommendations The recommendation to provide visual prompts and signage is still valid. The recommendation to record the outcomes of accidents and incidents is still valid. The registered person should find alternative ways to monitor the weight loss or gain of residents who are reluctant to be weighed. Ivy House Nursing Home DS0000042291.V280655.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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