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Inspection on 22/11/05 for Littleover Nursing Home

Also see our care home review for Littleover Nursing Home for more information

This inspection was carried out on 22nd November 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has developed a good administrative structure, the records and general recording of information is maintained well. Staff appear to work well as a team. Staff respond to residents needs promptly and in a sensitive and caring manner.

What has improved since the last inspection?

The environment has improved considerably new beds, carpets and anew boiler/heating system has been fitted. The further development of administrative structures and systems continues to improve. The registered provider continues to reinvest in the home to meet the requirements made.

What the care home could do better:

Staff training must be a priority 50% of care staff must achieve National Vocational Qualification at level 2.Water temperatures must be regulated to around 43c. A Quality Assurance structure would help to identify areas of care that could be improved/further developed.

CARE HOMES FOR OLDER PEOPLE Littleover Nursing Home Littleover Nursing Home 149 Stenson Road Littleover Derby DE23 7JJ Lead Inspector Gail Meads Unannounced Inspection 22nd November 2005 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 Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Littleover Nursing Home Address Littleover Nursing Home 149 Stenson Road Littleover Derby DE23 7JJ 01332 760140 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) Far Fillimore Care Homes Ltd Mr Chander Goel Mrs Mary Joanne Barker Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2005 Brief Description of the Service: Littleover Care Home is a large brick building set in its own landscaped gardens.The home provides accomodation for 40 older persons who have nursing care needs. There are both single and double bedrooms available only one room has en-suite facilities provided, however all the bedrooms have a television and telephone provided. Services provided include 24 hour staffed care, personal laundry, access to a wide range of health services and social and leisure activities Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over a four and a half hour period. Additional time was spent in preparation for the visit, looking at previous reports and other documents. During the inspection process a number of documents were examined, including residents’ care files, staff files and records, time was spent looking around the building and speaking to a number of residents, and to the manager and staff. The inspector spent a specific amount of the inspection concentrating on the care arrangements for the three residents for the purpose of case tracking. What the service does well: What has improved since the last inspection? The environment has improved considerably new beds, carpets and anew boiler/heating system has been fitted. The further development of administrative structures and systems continues to improve. The registered provider continues to reinvest in the home to meet the requirements made. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 6 What they could do better: 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. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 7 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 Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 8 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): 1.2.4.5.6. The admission and assessment process is clear and accessible, The Statement of Purpose and Residents Information Guide are detailed and informative. EVIDENCE: The home has a Statement of Purpose and Resident Information Guide in place both are displayed in the entrance area both documents are detailed and informative the amendment required and identified in the last inspection report had been made. The information given to residents prior to being placed at the home enables residents/relatives to make an informed choice about whether the home will meet their needs. Residents are offered trial periods, however a number of residents had received respite care prior to obtaining a permanent place of residency. Residents are given a contract/Terms and Conditions of residency these documents were examined and found to meet requirements. Standard 6 - this service is not offered at this home. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 9 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): 9.10.11. Individual care plans based on information taken from the needs assessments are in place. Medication is stored and administered as required. EVIDENCE: The deputy manager stated that there were no residents capable of self medication at the time of the inspection. Medication is stored safely and the administration of medication was observed during the inspection. The home has an up to date Administration of Medication policy in place. Staff were observed responding to residents needs in a sensitive and caring manner staff knocked on residents door before entering. Residents preferred form of address was used during the inspection. Staff responded to residents needs promptly the residents spoken to said that they felt that staff did respect them. Information about residents’ funeral arrangements was dealt with at the point of admission where possible and noted on their care plan. The deputy manager stated that when a resident was dying the general practitioner was consulted and the needs of the resident were identified if Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 10 nursing was needed then the Macmillan or Marie Curie nurses would be requested. The family would be involved if appropriate and relatives/friends can visit at any time. The residents spiritual needs would be met and the resident would not be left alone. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 11 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): 14. Residents are offered a number of ways to enable them to have control over their own life. EVIDENCE: Residents meetings are held six monthly minutes from the last meeting were examined and it was noted that a wide range of issues that concerned residents daily living were discussed these included the food provided and menus and activities. Residents can participate in their reviews if appropriate. Residents are given the option of self medicating and can also handle their own finances if appropriate. Locks are fitted to residents’ doors and keys are provided to residents who have the ability to use them safely. All residents are encouraged to retain their right to vote. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16.17. Complaints are dealt with promptly and appropriately. EVIDENCE: There is one ongoing complaint being dealt with at the moment it is not of an abusive nature and the Commission for Social Care Inspection is involved. The complaint is being dealt with according to the homes own complaints policy. A complaints policy is displayed in the front entrance of the home and is included in the Statement of Purpose and the Residents Information Guide. The deputy manager stated that should a resident need legal advice then either a solicitor or an Age Concern/Care Aware advocate would be invited in to help support the resident. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 13 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): 22.23. The general maintenance of the home internally and externally is improving. EVIDENCE: A range of lifting equipment is provided to enable residents to be moved safely by staff. Toilet and bath aids are provided to enable residents to toilet and bathe safely. A random number of residents bedrooms were assessed including the residents rooms used for the purpose of case tracking, one upstairs bedroom was found to be very sparse and did not include all the items of furniture as identified in Standard 24. Other bedrooms assessed had all the required furniture including bedside lamps, two double power points, domestic lighting and a call system. Radiator covers have now been fitted to all the radiators in the building. Locks are fitted to residents’ bedroom doors. There is still no lockable storage provided and some of the furniture and furnishings need to be replaced due to general wear. Some of the bedding was found to feel thin. Residents spoken to during the inspection stated that they liked their bedrooms and no complaints were expressed. A visitor spoken to during this inspection stated that the bedroom provided for their relative was alright. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 14 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): 28.29.30. The home has a recruitment procedure in place however it is not always adhered to. Staff training is generally improving. EVIDENCE: Staff are now being given more training opportunities although not all the staff at present have attended Adult Protection training the deputy manager did state that this training was now booked for the remaining staff. Two staff files were examined and one file did not contain any proof of identity and there were no references available for inspection. Both members of staff had had the appropriate police and health carried out before their employment commenced. Application forms had been completed and the interview process was clearly demonstrated. Staff are now being given a wider range of training than previously noted. However only 30 of the care staff have achieved National Vocational Qualification (NVQ) at level 2 and above. The deputy manager stated that there were another 5 in the process of completing their NVQ level 2 and this would then put them at over 50 as required. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 15 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): 33.34.35.36.37. Records are generally well maintained. Quality Assurance systems are not in place. Staff receive regular supervision and all staff receive an induction period when they commence employment. EVIDENCE: There is still no Quality Assurance systems and structure in place for the monitoring and evaluation of the services provided to residents this includes the publishing of a report available to residents/relatives. The information is used to promote the development of appropriate services to residents. Regulations 26 had been completed by the provider and were up to date. The home can make the homes accounts available for inspection if needed. Relatives deal with all residents’ monies and financial matters and the home does not hold any residents money. There were induction and supervision minutes completed. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 16 Training programmes are now maintained for all staff. Staff receive supervision at least six times per year as required and a record can be found on staff files. A number of records were assed during this inspection including accidents, complaints, staff files, staffing rotas and the Statement of Purpose all were maintained as required apart from the staff recruitment issues as previously mentioned in Standard 27 of this report. The home has a comprehensive Policies and Procedure manual in place. Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 17 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 x 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x x x x 2 3 x x x STAFFING Standard No Score 27 x 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 3 3 3 2 x Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 18 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 OP29 Regulation 19(1)(a) (b) and (c) 24 Requirement The registered person must ensure that all the documentation as identified in Schedule 2 is in place on staff files. The registered person must ensure that a Quality Assurance structure is developed and systems to monitor and evaluate the information is put into place. The previous timescale given was 01/08/05 The registered person must ensure that water temperatures are regulated to around 43c. To prevent risks from scolding pre-set valves of a type unaffected by changes in water pressure and which have failsafe devices are fitted locally to provide water in baths and showers at a temperature close to 43c. An Immediate requirement was left at the last inspection dated 31/05/05 The registered person must ensure that any damaged furniture in residents bedrooms DS0000059788.V266291.R01.S.doc Timescale for action 01/02/06 2 OP33 01/02/06 3 OP25 13 01/01/06 4 OP24 23 01/03/06 Littleover Nursing Home Version 5.0 Page 19 5 OP20 23 6 OP19 24 7 OP88 15 8 OP24 16(2)(c) 9 OP3 14 must be replaced. The registered person must ensure that all areas accessible to residents including the gardens areas are kept safe for residents to use. The previous timescale given was 01/08/05 The registered person must ensure that lockable storage is provided for residents in their bedrooms. Where identified that a resident has lost weight, is underweight or is malnourished a clear care plan must be put in place to show how this is being managed. The previous timescale given was 01/08/05 The registered person must provide bedding that is of good quality and appropriate to ensure that residents are always warm. Staff must complete a full assessment of residents’ need and preferences to enable them to meet the identified needs. The previous timescale given was 01/08/05 01/06/06 01/03/06 01/02/06 01/02/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Littleover Nursing Home DS0000059788.V266291.R01.S.doc Version 5.0 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!