Inspection on 08/01/08 for Ivy House Nursing Home

This inspection was carried out on 8th January 2008.

CSCI found this care home to be providing an Adequate service.

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

Ivy House Nursing Home 26/09/08

Ivy House Nursing Home 30/10/06

Ivy House Nursing Home 14/03/06

Ivy House Nursing Home 14/12/05

Ivy House Nursing Home 20/01/05

Ivy House Nursing Home 25/05/04

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Hawkhills

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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 Ivy House Nursing Home Hollin Wood Close Moorhead Lane Shipley West Yorkshire BD18 4LG Lead Inspector Chris Levi Key Unannounced Inspection 8th January 2008 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 Ivy House Nursing Home DS0000042291.V352286.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. Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 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.V352286.R01.S.doc Version 5.2 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 cerificates are issued as part of this process. 30th October 2006 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 of 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. The home’s weekly charges at the time of the inspection range from £495.39 to £1223.88. There are additional charges for chiropody and hairdressing. Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Information about the home requested by the Commission for Social Care Inspection included a new document, the Annual Quality Assurance Assessment (AQAA) was completed by the home manager and returned to the CSCI. This enabled the inspectors to analyse information that included the number of reported accidents, complaints and compliments from residents and relatives and other relevant information to help plan for the visit to the home. It also provided opportunities to demonstrate how the home could improve its services to the people who live at the home. The providers were not notified of this inspection in advance. This enabled the inspectors to observe how the home is run on a day-to-day basis, without any changes being made to the usual routines of residents and staff. The visit started at 9.30 am and finished at 5.30pm. The person in charge of the home was the owner/Manager Mr Berry. As the home provides care for people with dementia, two inspectors visited the home. One focussed on the quality of life and care for a number of people in the home with dementia, using a study method extensively used by the CSCI to evaluate the well being of people with dementia. The other inspector spent time talking to residents, relatives, and staff, to find out what it is like to live, work and visit Ivy House. A number of documents were reviewed relating to residents, staff and health and safety. Twenty residents, and twenty relative survey forms, plus ten staff surveys and three external health professionals were sent to the home before the visit to enable them to provide the Inspector with opinions about standards at the home. One resident survey was returned and indicated the person was satisfied with the care provided. Five staff surveys were returned. One was less positive than the remaining four, who felt they were supported and trained to do their jobs by the management team One returned survey from an external health professional was positive about the standards of care provided at the home. One comment was, “Always looking to do their best for all clients.” Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 6 Mr Berry, the Manager and a senior member of the staff team were given feedback about the findings of the inspection at the end of the visit. What the service does well: What has improved since the last inspection? What they could do better: Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 7 The home has introduced a new system to record the needs of residents. Most of the information is held on a computer and there are paper copies of some information. Whilst this is detailed, there was a lack of a person centred approach in the information held. Generally, there was evidence that identified a resident’s needs but no information for staff as to how those needs should be met. This could lead to an inconsistent approach by staff when providing support to residents. It was also identified there was nowhere on the new system for resident or relative to sign that they had agreed to the plan of care. The owner identified a solution to this during feedback. Generally, staff were observed having a task-focused approach to their role as carers. Refering to the group of people who need assistance with feeding at mealtimes as “feeders” is poor practice. It is demeaning for residents and indicates a lack of person centred approach to individual care needs. To enable resident independence, the owners should consider introducing a large menu board displayed in the home, to inform residents what food is on offer that day. Nurses administering resident medication must not leave medication in resident’s room. This is poor practice, as there is no evidence that the resident takes the medication, and may lead to their ill health. The managers involved in staff recruitment should investigate gaps in employment history on application forms for new workers, to ensure they are suitable to work with vulnerable adults. A record of all recruitment documents must be kept on the individuals staff file. This includes a passport photo and other documentation to confirm their identity. Again, this helps to ensure people suitable to do so care for residents. The manager must ensure staff undertake an induction programme which complies with the Skills for Care, Common Induction programme. Also all staff must undertake training in caring for people with dementia, Infection Control, and Safeguarding Adults from Abuse to ensure they are competent to care for people living at Ivy House. It is positive to note that the training coordinator at the home did state that she was currently registering the home with the Skills for Care Council to enable this training to take place in the future. 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. Ivy House Nursing Home DS0000042291.V352286.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 Ivy House Nursing Home DS0000042291.V352286.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): Standards 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is written information about the home to help people decide if they wish to live there. The needs of prospective residents are adequately assessed to ensure staff can meet their needs. EVIDENCE: Documentation about services provided by the home is available in writing. It also includes pictorial information that could be further developed, to help those people with dementia who have difficulty reading. It is displayed in the entrance hall, and sent out to people who want to know about the home and its services. Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 10 There was evidence that the assessed needs of people before they move to the home are detailed. This provides staff with opportunities to develop effective plans of support in preparation for the person as they move into the home. Residents or their representatives are given annual updates on the fees charged by the home as part of their contract of occupancy. This is good practice. Ivy House Nursing Home DS0000042291.V352286.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): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ care plans identify their personal and health care needs. However, they need to be further developed to ensure staff know how to consistently meet the individuals needs. The dignity and respect for residents is not always maintained. Poor practice relating to the administration of residents medicines by staff could put the health of residents at risk. EVIDENCE: The documentation for two residents was looked at in detail. This was to establish if the written plans of care produced by nurses, provides clear information about the care needs of the individual. In the plans there was evidence, on a computerised system (some of which was also in paper copy) of significant detail about individual support and nursing needs once they moved to the home. There was information about visits from an external health Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 12 professional, when nurses at the home decided they needed specialist support for the resident’s ongoing well-being. The plans recorded regular visits by external health professionals to support the home staff with some health needs of residents. There was evidence of action to be taken if a resident is involved in an incident or accident that may affect their wellbeing. A senior member of the management team reviews the plans regularly. Relevant changes in needs are documented in the care plans. Risks to residents were identified and actions to reduce the risks are in place. The shortfall with the plans is, that they do not identify in sufficient detail how staff should undertake to provide support to individual residents. This could lead to an inconsistent approach by staff when providing support to residents. An example observed during the visit was discussed with the manager to demonstrate how a resident’s specific need should be detailed, to enable staff carry out personal care whilst maintaining the dignity of the resident. Staff were observed not informing residents of action they were taking thus taking the resident by surprise, examples seen included leaving food on a resident’s table without informing them it was there, tipping residents in wheelchairs backwards as the chair was moving. Referring to the group of people who need assistance with feeding at mealtimes as “feeders” is poor practice. It is demeaning for residents and indicates a lack of respect for individuals. This matter was discussed with the management in some detail as the practice continues despite having been mentioned at the last inspection. The introduction of a person centred approach to gathering relevant information about residents’ lives before they move to the home will provide staff with the opportunity to deliver a more individualised approach to the support they give to residents. During the visit it was noted that the nurse in charge had left a resident’s medicines in the resident’s room. This is poor practice as there is no way of knowing when, if, or who has taken the medicine. This could affect the health of residents. Nurses should take the medication administration record to the resident when administering their medication. This should reduce the risk of failing to sign for medication given. When administering controlled drugs to residents, nurses should train care staff to act as witness to the administration of the drug, to minimise the risk of errors. Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 13 Medicines are stored safely, and checked to ensure they are correct when they arrive from the pharmacist. This reduces the risk of a resident’s medication being incorrect. The medication fridge temperatures should be taken and recorded daily to ensure medicines are stored at the recommended temperature. Ivy House Nursing Home DS0000042291.V352286.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): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities for the people living in the home have improved, and are relevant to people with dementia. Within the social and physical limitations of individuals, there is choice regarding how, and where, they spend their day. EVIDENCE: A personal history profile document is sent out to relatives for completion soon after their family member moves into the home. This helps the home identify the likes and dislikes of the individual, as well as providing a useful record of key events to which the family have contributed. This is good practice. On the day of the inspection we saw some evidence of activities taking place, such as staff playing catch with beanbags, one person having their nails done and people watching television. One family were seen to be completing a jigsaw with their relative. Staff told us about a quiz night that had taken place in November and about activities that had taken place over the festive period. Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 15 During the period of time, using the SOFI (short observational framework for inspectors), we saw that some people did not receive any attention from staff other than assistance with tasks. People who were more able to respond verbally received more attention. We saw that there were several missed opportunities where staff could have conversed with people such as when helping them with their breakfast or leaving a tray on their table. The social activities undertaken by each person are recorded on a daily sheet. One record was looked at for the week commencing 31st December 2007. .One person who had been at the home for 3 weeks had not been added to the list. On one day 10 people watched television, 10 listened to music whilst others had some 1-1 activity. We were told that 1-1 activity could be going for a walk, going on a trip out to the park, or enjoying some quiet time in their room with staff or a Jacuzzi bath with sensory lights. The home employs a part-time activities coordinator. She was previously responsible for organising trips and activities and will now be involved in training up two staff members dedicated to taking on this role on a supernumerary basis. We saw resource files being developed on organising quiz nights, 1-1 sessions trips out and so on. There are plans to taking further advice from the home’s membership of NAPA (National Association for Providers of activities for older people) a voluntary organisation which helps develop understanding and skills in relation to activities for older people. For those residents cared for in their room, the manager should provide a contact sheet to enable staff to record when and what they did when visiting the resident. This should demonstrate the resident is not socially isolated for long periods of time, which may affect their well being. Religious needs are identified and one person visits a place of worship with their family. We saw that visitors are welcomed into the home. An environmental health inspection had been carried out in December and the provider told us that plans were in place to replace flooring, a cooker and fridge. We saw a completed record for fridge and freezer temperature checks. A temperature check is carried out of food served using a Bain Marie and of hot food prepared at lunchtime. The temperature of hot food served at other times should be checked to reduce the risk of scalding. People were offered drinks throughout the day. The assistant cook stated that sandwiches and cakes are available for residents, should they want food during the night. All food served to residents is fortified with additional calories to Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 16 ensure the food they eat has maximum nutritional value to maintain or improve their well-being. On the day of inspection the lunchtime meal was observed. People had a choice of chicken pie or gammon served with seasonal vegetables. People were offered salt and pepper and fruit squash. People who required a soft diet had the different components of their meal pureed separately to maintain appearance and taste. There were sufficient staff on duty to ensure that everyone got the help they needed. Staff who assisted people with meals sat alongside them and took their time. One staff member held the hand of the person they were helping to reassure them and others were seen to engage people in conversation. To enable resident independence, the owners should consider introducing a large menu board displayed in the home, to inform residents what food is on offer that day, as the writing on the menus displayed is very small. Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are provided with information about how to make a complaint. Staff are aware of the need to keep residents safe from abuse. EVIDENCE: Relatives said they were confident about making a complaint to the home if they needed to. They said the management team were approachable and they were confident that the complaints would be investigated appropriately. The complaints procedure is well displayed within the home and the records were appropriately kept. There was evidence that senior staff record and refer to external professionals any instances of violent incidents, to protect the well being of residents. In discussion with some staff, they said they had not received training relating to Safeguarding adults from abuse. In conversation they said they would report any concerns to the manager. However all staff need to be trained to understand, and recognise different types of abuse, to enable them to protect residents in their care. Ivy House Nursing Home DS0000042291.V352286.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): Standards 19, 20, 21, 22 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides satisfactory, safe accommodation for service users, and facilities for staff who work in the building. EVIDENCE: The fire protection systems within the home have been improved. This should help staff identify the location of a fire quickly, and maintain the safety of the residents. Internal redecoration and refurbishment of the home is ongoing. New carpet in the downstairs communal areas is attractive, but is so patterned it is could be a hazard for residents with dementia, as they bend down to pick at the pattern. Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 19 One resident’s room was being fitted with a shower room during the visit, he was very excited bout this. Work to replace flooring in the laundry, kitchen and some areas of the ground floor corridor has been identified, and suppliers were visiting to offer the provider suitable options on the day of the visit. The communal space is divided into a number of small lounges and a separate dining room. This provides a choice for residents as to where they sit. They were furnished in a homely way with photos and paintings of previous generations. The communal toilets had signs, both in writing and pictures, to aid some residents find the toilet without assistance, and maintain their independence. Two bathrooms on the first floor were not in use during the visit. The owner said they are to be refurbished. A carpet on the first floor was noted to be a hazard as it was splitting at a join. This was immediately made safe by the in-house maintenance team. In a shared room the privacy curtain between the two beds was missing. This would compromise the dignity and privacy of the two residents who occupy the room. The home was clean and free from odour. Ivy House Nursing Home DS0000042291.V352286.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): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment of staff is satisfactory, but improvements would further protect people living in the home. New staff would benefit from a more detailed induction programme to ensure they can meet the needs of residents. EVIDENCE: The numbers and skills mix of staff on duty at the time of the visit was satisfactory to meet the needs of the 40 residents in the home. The home does have a recruitment policy in place. Two recruitment files were looked at. There was evidence that the home’s policy is followed but more attention should be paid to explore the gaps in an applicant’s employment history, to ensure they are safe to work with vulnerable adults. All staff files must contain the documents identified in the Regulations Schedule Two, to ensure their identity can be verified. The home currently has 35 of care staff with a formal care qualification. The remaining staff are working towards this award. Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 21 Staff must undertake an induction programme that complies with the Skills for Care, Common Induction programme. None of the staff have undertaken training in Infection Control. This could result in staff unknowingly working in ways that would put themselves and residents at risk from infection. Not all staff has undertaken training in dementia care or safeguarding and understanding adult abuse. Again, this may be putting residents at risk. Ivy House Nursing Home DS0000042291.V352286.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): Standards 31, 32, 33 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed for the benefit of residents, relatives and staff. EVIDENCE: Mr P Berry is the owner/manager of Ivy House. He has many years experience of managing care homes for people with dementia. He also has a relevant management qualification. Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 23 Relatives, residents and staff who spoke with the inspectors said the manager was approachable and open to suggestions to improve services provided at the home. There was evidence a quality review had been undertaken by the management team. This involved surveys sent to staff, relatives, and residents. However, no action plan and findings report was produced as a result of the analysis of the information received. A report available to those people who took part in the review would inform them of any changes made to the services, as a result of the review. The home employs an in-house maintenance person who has responsibility for a number of health and safety checks around the house. There were records of these checks, and they were up to date. A number of certificates for the maintenance of equipment were looked at and were up to date. The only document not available was the 5 year electrical hard wiring certificate. This document should be available within the home as it confirms the wiring within the building has been checked by a professional and is not a fire risk. Ivy House Nursing Home DS0000042291.V352286.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 3 3 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x 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 3 x 3 x x x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x x x 3 Ivy House Nursing Home DS0000042291.V352286.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 Requirement Timescale for action 30/01/08 2. OP7 15 3. OP10 12 4. OP28 18 Nurses administering resident medication must do so in a safe way to ensure the medicine is taken at the right time by the right person to maintain their health well being. 31/03/08 The manager must ensure staff are given detailed information relating to the care needs of residents to enable them to provide the correct, consistent standards of care support to individual residents. The manager must ensure the residents or their representatives are involved with the development of care plans and risk assessments sign to agree with the care plans proposed. The registered person must 28/02/08 ensure residents’ dignity is upheld within the care plan documentation and also with the attitudes held by some staff members. The registered person must 31/03/08 ensure at least 50 of the carers working in the home are trained to at least NVQ level 2 DS0000042291.V352286.R01.S.doc Version 5.2 Ivy House Nursing Home Page 26 standard. Also that all staff receive appropriate training in Adult Protection, Infection Control and dementia care. Staff must undertake an induction programme that complies with the Skills for Care, Common Induction programme. 19 The manager must ensure, that Schedule when recruiting new staff, gaps 2 in employment on an application Regulation form are explored to ensure the 19 person is suitable to work with vulnerable adults. Staff recruitment documents must comply with Schedule 2 to confirm the authenticity of the person. 5. OP29 28/02/08 Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 27 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 OP9 Good Practice Recommendations A member of staff should witness the administration of controlled drugs to ensure they are given to the right person at the right time. The medication fridge should have a record of daily temperature to ensure it is maintaining medication at the correct temperature. For those residents cared for in their room the manager should provide a contact sheet to enable staff to record when and what they did when visiting the room. This should demonstrate the resident is not socially isolated. To enable resident independence, the owners should consider introducing a large menu board displayed in the home, to inform residents what food is on offer that day, as the writing on the menus displayed is very small. The 5 year electrical hard wiring certificate should be available for inspection by external professionals, as it confirms the wiring within the building has been checked by a professional and is not a fire risk. Activities for residents should be person centred to include one to one sessions for those unable or unwilling to take part in group activities. 2 OP10 3 OP15 4 OP38 5 OP12 Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Extracts may not be used or reproduced without the express permission of CSCI Ivy House Nursing Home DS0000042291.V352286.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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