Inspection on 23/05/05 for Littleover Nursing Home

This inspection was carried out on 23rd May 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.

Other inspections for this house

Littleover Nursing Home 15/05/07

Littleover Nursing Home 22/11/05

Littleover Nursing Home 13/01/05

Littleover Nursing Home 20/09/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

CARE HOMES FOR OLDER PEOPLE Littleover Nursing Home Littleover Nursing Home 149 Stenson Road Littleover Derby DE23 1JJ Lead Inspector Angela Kennedy Key Unannounced Inspection 23rd May 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Littleover Nursing Home DS0000059788.V294741.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. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Littleover Nursing Home Address Littleover Nursing Home 149 Stenson Road Littleover Derby DE23 1JJ 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) Inhome149@aol.com 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.V294741.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: Littleover Care Home is a large brick building set in its own landscaped gardens. The home provides accommodation for 40 older persons who have nursing care needs. There are both single and double bedrooms available only one room has ensuite 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 Information regarding the home and fees payable is available by contacting the home by telephone or email. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced key inspection, which looked at all of the National Minimum Standards. The inspection took place over 4 hours. 3 residents files were seen and 3 staff files. Other documents relating to the practices of the home were also examined. Several residents were spoken with and two members of staff. The matron of the home was available throughout the inspection to provide any information requested. What the service does well: What has improved since the last inspection? The refurbishment of the home continues, this includes new beds, wardrobes, tables and carpets, which demonstrate the registered providers commitment to improve the home to meet the requirements made. A professionally recognised quality assurance system is now being put into place within the home, this will ensure that systems are in place to measure the success of the home in meeting the aims, objectives and the homes statement of purpose. Pre-set valves are now in place on hot water taps used by or for the residents, which ensure that the water temperatures are regulated to around 43c, this prevents a risk of accidental scalding, and thereby ensures resident’s safety is maintained. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 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.V294741.R01.S.doc Version 5.1 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.V294741.R01.S.doc Version 5.1 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): 2,3,5 Each resident had a written contract with the home and assessments were undertaken prior to resident’s moving into the home to ensure their needs can be met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: 3 residents contracts were seen and all had a statement of the homes terms and conditions. Of the 3 residents files seen all had in place assessments that had been undertaken prior to admission which looked at all areas of need including; personal safety, communication, breathing, nutrition, elimination, personal hygiene, mobility and comfort, social interaction, personality and spirituality, sleeping and skin integrity. This demonstrates that detailed assessments are in place on admission, which permit accurate careplanninng to be implemented from this information. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 9 Trial visits to the home were not part of the standard practice, however the matron did confirm that should a prospective resident wish to access the home for a trial period this could be arranged. The home did offer respite; this was subject to the availability of a bed. One resident spoken with, who had lived in her own home independently, said that she had been to the home for respite and liked it so much that she decided to return on a permanent basis. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Resident’s health, personal and social care needs were set out in a plan of care, which included access to health care services. The care provided ensured that the resident’s welfare was protected by the homes policies and procedures Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: The 3 residents files seen all demonstrated that the care plans in place had developed from the resident’s needs assessments (see standard 3). All contained detailed information regarding the assistance and support that each resident required to maintain their welfare. Assessments were also in place to ensure that resident’s health was maintained and promoted. This included assessments on tissue viability to ensure that residents prone to pressure sores were identified and the appropriate treatment/action taken. Assessments were in place regarding nutrition, moving and handling and risk of falls. A health profile was also in place in the files seen this was for recording residents weight, temperature, blood pressure and any other health care needs, such as blood sugars. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 11 Visits from General Practioners, chiropodists, dentists, opticians and clinic visits were also recorded. Of the 3 residents files seen, evidence was in place to demonstrate that the residents care plans were reviewed on a monthly basis, this ensures that the changing needs of residents are continuously reviewed and updated as required. There was no evidence in place within the 3 residents files seen to demonstrate that the residents had been consulted or were in agreement with their written plans of care. The matron said that many of the residents were unable due to poor health to be consulted regarding their care plans. However to demonstrate that the home strives to promote the residents autonomy, residents who are able, should be encouraged to participate in the formulation of their care plans and sign in agreement to them. To promote an open, inclusive, approach to the care provided, residents representative should be asked to sign the care plans for any residents who are unable to do. There were no residents on the day of inspection that self-administered their medication. The medicines stored within the medication trolley and cabinets were seen and contained the appropriate pharmaceutical labels/instructions. The medication administration records were seen and were satisfactory. A list of the staff names and initials that administered the medication was on display, so that staff’s initials on the medication administration records could be identified if needed. The residents preferred name was documented on the three files seen which demonstrates that the home is respectful of the resident’s wishes. It was observed during the inspection that many of the residents had failing health, however it was noted that staff showed respect and consideration when providing care to these residents. Residents spoken with were complimentary in their comments regarding the staff team. One resident stated, “They are all very kind and look after us well”. Information regarding arrangements following death was seen in one resident’s file that was looked at. The matron said that she found it quite difficult to discuss issues regarding resident’s wishes on dying or death at the point of admission to the home, and felt that this was better dealt with at the appropriate time when discussions with relatives mainly took place. Issues regarding the arrangements following death or the arrangement for care to terminally ill patients should be sought according to the needs and wishes of each resident and at time considered suitable for the resident and their families/representatives. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Residents maintained contact with their families and friends and residents independence was promoted. Social, personal and religious preferences were identified within resident’s files and within the homes practice. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Residents spoken with confirmed that they were able to retire to bed when they chose to and said that they were able to get up at a time convenient to them. Resident’s breakfasts were taken in their own private accommodation, unless they preferred to eat breakfast in the dining room. This allowed residents who wished to get up at their leisure an opportunity to do so. In the 3 residents files seen evidence was in place that identified their social and religious preferences and need. An activities co-ordinator was employed at the home, although she was not available to speak with on the day of inspection. The activities provided at the home included; bingo, quizzes, board games, craft work- such as card making, music and movement and sing-a-longs. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 13 Entertainment of different varieties was provided from external sources on a monthly basis. Although day trips were not usually planned due to the frailty of the majority of residents, residents that were able were escorted out into the local community by the activities co-ordinator if they wished to do so. A hair stylist visited the home twice a week for residents who wished to use this service and a separate hair salon room was provided in the home. Visiting hours at the home were open, however the matron said that she tried to discourage visiting at lunchtime in order to allow for protected meal times for the residents. Residents were able to receive their visitors within their private accommodation or within communal area of the home, whichever suited their needs and choice. Residents and/or their relatives managed their own financial affairs. There were 2 choices offered at meal times although alternatives were provided to these choices if required. Residents spoken with were happy with the meals provided and confirmed that alternative meals were available if they did not want the choices on the menu. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 14 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): 16,18 A simple, clear accessible complaints procedure was available at the home and residents were safeguarded from abuse by the homes procedures and practices. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A concern had been raised regarding a resident no longer living at the home. The Commission for Social Care Inspection had been notified of this, and Derbyshire Social Services had investigated this concern and following the investigation concluded that no further action was required. The complaints procedure, which was displayed in the entrance hall and included in the resident’s statement of purpose and information guide. This procedure was clear and included stages and timescales for responding and dealing with complaints as required. The complaints log was also examined and two complaints had been made this year. The records of these complaints were very brief and did not set out clearly the details of the complaint and how the complaint was resolved. However it was noted that the format used to document complaints in 2005 did provide this information, it is therefore recommended that this format be used again rather than the current format. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 15 Adult protection was provided for the staff at the home and this was evidenced within the staff files seen. Procedures were in place at the home for responding to suspicion or evidence of abuse or harm. Staff spoken with confirmed their understanding of these procedures. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 16 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): 19,23,24,26 The homes maintenance programme continues to demonstrate improvements throughout the property, and when completed this will enhance the environment for residents to ensure their safety and comfort is maintained Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: All rooms within the home are undergoing refurbishment. The matron stated that the majority of ground floor refurbishment has been completed. New hospital beds, wardrobes and bedside tables have been purchased and carpets are being replaced where needed. Refurbishment of the first floor rooms has not as yet commenced Bedding was being replaced as part of the refurbishment programme. Lockable facilities with resident’s own private accommodation are being fitted as part of the refurbishment programme. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 17 Screening is provided in shared rooms to ensure resident’s privacy is maintained when required. Areas of the garden that were assessed as unsafe for residents due to steep steps have now been made inaccessible by providing a barrier. Plans are in progress to extend the home the inaccessible part of the garden is the area that will become part of the extension and the existing area will be levelled off to provide a safe area for residents to use if required. The general cleanliness of the home was noted and found to be of a good standard. The laundry facilities were situated away from the main building and the laundry staff managed all laundering of resident’s clothes and the homes linens. Hand washing facilities were available within all bathroom and toilet areas. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Residents needs can be met by the number and skill mix of the staff team, and residents are protected by the homes recruitment and training practices. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to the service. EVIDENCE: The homes operates using ‘Teams for Care’, there are five teams in total. Included in each team are 1 key worker and 1 named nurse. This demonstrates that structure and skill mix are provided. 12 Qualified nurses are employed at the home, which include the manager and deputy. 27 care staff are employed at the home and 14 of these staff have achieved a National Vocational Qualification (NVQ) in care at level 2. The ratio of care staff with an NVQ 2 therefore meets the national required target of 50 . The numbers of staff on each shift on the day of inspection were; morning shift 1 nurse and 7 care staff, afternoon shift 1 nurse and 6 care staff and the night shift 1 nurse and 3 care staff. The manager was working from 9am to 5pm. Other staff on duty at the home included domestic staff, catering staff and the homes administrator. A variety of training courses were available to staff and evidence was in place in the staff files seen that training was undertaken, including induction on commencement of employment. The recruitment practices of the home were seen within the staff files examined and contained all the required documents, such as satisfactory Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 19 criminal records bureau checks, full employment history’s, sufficient proof of identity including photo id and 2 satisfactory written references and proof of qualifications obtained. Residents spoken with stated that they felt there were enough staff on duty at the home to support their needs, and commented that staff were always prompt when they required assistance. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 20 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): 31,32,33,35,38 The matron/registered manager has the skills; qualification, competencies and experience required to manage the home and demonstrate a clear sense of direction and leadership. The Quality Assurance systems of the home are at present in the development stages and therefore require further work. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The matron has 16 years experience in nurse management and has been the manager/matron of the home for the last 2 ½ years. The manager is a registered nurse and has achieved the registered managers award. Evidence was in place, which demonstrated that the matron communicates to the staff team a clear sense of direction. This was seen within the daily routine guidance that had been developed for the staff team and in the supervision records seen within the staff files examined. Staff spoken with confirmed that Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 21 they enjoyed working at the home and felt the matron ran the home in an open and inclusive way. Residents and/or their relatives kept their own monies. The home did not hold monies for any resident. The home had recently changed their Quality Assurance systems to a professionally recognised system. This system was not as yet up and running. Matron confirmed that the new system should be in place within the near future; this will then allow the home to demonstrate how residents influence the running of their home. Quality audits regarding the general maintenance and practices of the home are undertaken on a monthly basis, this includes audits on medication, catering, accidents, laundry and environment. The handyman maintains the homes weekly fire alarms tests and general maintenance. Training has taken place with regard to moving and handling, infection control, food hygiene, first aid and fire safety for the staff team. Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 22 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 X 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 X 3 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 3 2 X 3 X X 3 Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 23 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. 2. Standard OP19 OP24 Regulation 24 23 Requirement Lockable storage must be provided for residents in their bedrooms. Any damaged furniture in resident’s bedrooms must be replaced. (Previous timescale 01/03/08) The homes Quality Assurance structure must be developed and systems must be in place to monitor and evaluate the information provided. (The previous timescale given was 01/08/05 and 01/02/06) Timescale for action 01/02/06 01/02/06 3. OP33 24 01/01/06 Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 24 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 OP11 Good Practice Recommendations Evidence should be in place to demonstrate that residents (when able) or their representatives (if any), have been involved and consulted about the care given to them at the home Littleover Nursing Home DS0000059788.V294741.R01.S.doc Version 5.1 Page 25 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.V294741.R01.S.doc Version 5.1 Page 26 - 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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