Inspection on 14/09/07 for Longley Park View Nursing Home

This inspection was carried out on 14th September 2007.

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

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

Other inspections for this house

Longley Park View Nursing Home 19/09/06

Longley Park View Nursing Home 07/11/05

Longley Park View Nursing Home 12/04/05

Longley Park View Nursing Home 14/12/04

Longley Park View Nursing Home 22/07/04

Longley Park View Nursing Home 17/03/04

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

CARE HOMES FOR OLDER PEOPLE Longley Park View Nursing Home 70 Longley Lane Sheffield South Yorkshire S5 7JZ Lead Inspector Ramchand Samachetty Key Unannounced Inspection 14th September 2007 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 DS0000021794.V337808.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. DS0000021794.V337808.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Longley Park View Nursing Home Address 70 Longley Lane Sheffield South Yorkshire S5 7JZ 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) 0114 242 5402 0114 242 5452 none None Longley Health Care Limited Mrs Margaret Johnson Care Home 67 Category(ies) of Dementia - over 65 years of age (38), Mental registration, with number disorder, excluding learning disability or of places dementia (11), Mental Disorder, excluding learning disability or dementia - over 65 years of age (18) DS0000021794.V337808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The numbers of care staff and qualified nurses on duty at any one time must be determined and provided according to the assessed needs of service users. Staffing levels must be maintained at at least those described in the document accompanying the variation application, reference number `JQ09/01/2003 confidential`. The building must be organised into the following groupings; 11 Mental Disorder (MD) - ground floor separate unit; 18 Mental Disorder for people 65 and over (MD/E) - ground floor separate unit; 38 Dementia for people 65 and over (DE/E) - first floor separate unit. The service may admit persons between the ages of 60 and 65 years into the Ecclesfield Unit MD(E). 19th September 2006 23 January 2007- Random Inspection. 2. 3. Date of last inspection Brief Description of the Service: Longley Park View is a care home, which provides both personal and nursing care for up to 67 residents. Thirty- eight places are for older people (over 65 years of age), eleven places are for people who are under 65 years and who suffer from mental disorder and a further eighteen places for people in the same group but over 65 years of age. Longley Park View is a purpose built home providing accommodation at ground and first floor level. The home is sited in a residential area and is close to local shops and a bus route to the North of Sheffield city centre. The home is organised into three separate units, each having its own communal areas, which include a kitchen facility, a lounge and bathrooms and toilets. Longley Park View is owned and managed by Longley Health Care Ltd, which is part of Exemplar Health Care. The weekly fees charged at the home, as at 14 September 2007, ranged from £432.00 to £1,800.00. This information was supplied to CSCI as part of the inspection process. The home has produced its statement of purpose and a service user guide, who give further information about the service it provides. Both documents and other information can be obtained by contacting the home manager. DS0000021794.V337808.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out on 14 September 2007, starting at 09.30 hours and finished at 19.00 hours. The service is registered to provide nursing and personal care for up to 67 people. There were 59 people in residence at the time of this inspection. The registered manager was on study leave and a senior manager of the Company was in attendance during the inspection. All the key national minimum standards for ‘Care Homes For Older People’ were assessed. Progress made following a ‘Random Inspection’ of the home by CSCI on 23 January 2007, was also checked. This key inspection included a tour of the premises, examination of care documents and other records, including those pertaining to staff rota, complaints, and maintenance of equipment and systems, staff and medicines records. The inspector spoke to a few people who live at the home and who could express their views independently, two relatives, one visiting health care professional and five members of staff. The care of three people was tracked and some aspects of care provision were observed. As part of the pre-inspection planning, the home’s ‘Annual Quality Assurance Self- Assessment’ and other documents, including comment cards received from people who use the service and their relatives, were considered. The views and comments of the people, who use the service and of their relatives, have been included in this report. The inspector would like to thank all the people who helped with this inspection. What the service does well: What has improved since the last inspection? DS0000021794.V337808.R01.S.doc Version 5.2 Page 6 The service user guide has been produced in visual form, to improve its access by people with communication problems. The physical environment of the home has been improved and further work is planned to make sure the place remains safe and pleasant. What they could do better: The care plans of people who use the service needs to be further improved to make sure they address all aspects of identified needs and that care provided is appropriately recorded and reviewed. Staff must make sure that all medicines received at the home are recorded in order that their use can be easily monitored. The storage of medicines should also be improved. Social and recreational needs of people using the service must be appropriately assessed and catered for. The plan of activities needs to reflect needs, preferences and capabilities of people concerned. The dining facilities and the meals service need to be reviewed in order to reduce ‘overcrowding and noise’ and to make mealtimes more of a social occasion that they can be, for people who live at the home. Although, people were satisfied with the meals provided at the home, the menu should be developed and presented in a way that gives them more choice. The menu should also adequately address the cultural and religious needs of people who use the service. Access to the call bell at the entrance of the building should be improved for the benefit of wheelchair users. Bedroom furniture for use by people living at the home must be improved to increase their comfort and safety. Records relating to the management of complaints and to the administration of personal monies of people using the service need to be improved in line with best practice. The manager should review and improve the facilities provided at the home for people who smoke, in order to comply with the smoke free legislation and also to protect people’s health. A recommendation has been made for the deployment of staff on duty to be based on the dependency of people living at the home and for the minimum staffing level to be observed at all times. DS0000021794.V337808.R01.S.doc Version 5.2 Page 7 Although staff training and development are addressed by the service, it should now include more efforts in providing training on ‘mental health issues in old age’ and on ‘Equality and Diversity’ to ensure that people’s diverse needs can be met. 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. DS0000021794.V337808.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 DS0000021794.V337808.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to the service. Adequate information about the service was provided to people who live at the home and to those who were interested in using it. This helped them to choose the home and to have details of the service so that they could make the best use of it. EVIDENCE: Information about the home and its services was provided to people who use the service and their representatives through the statement of purpose and the service user guide. The service user guide contained broad details about daily living arrangements and it also contained a copy of the last inspection report, which provided a view on the quality of care that was being provided. The operations manager stated that the service user guide was being published in DS0000021794.V337808.R01.S.doc Version 5.2 Page 10 a ‘visual format’ for the benefit of people who were unable to read the printed version. A relative said that her father and herself had found the inspection report very helpful in making their choice of a care home. They had also looked at the statement of purpose and spent time visiting the home before choosing the home. The care files of two people who had recently been admitted were checked. They had copies of full needs assessments which had been carried out before their admission. The home does not provide an intermediate care service. DS0000021794.V337808.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The health and personal care needs of people who use the service were met in a manner, which promoted their privacy and dignity. EVIDENCE: The individual care plans of three people who live at the home were checked. They were based on their assessed needs and preferences, which helped staff with their efforts to provide care according to peoples’ needs and wishes. Whilst personal and health care needs were addressed, social care needs were often less well assessed and inadequately addressed in care plans. The record of care provided was, in a number of instances, too simplified and generalised to be of effective use in evaluating care. The care records contained statements affirming that they had been regularly reviewed. However, there was no evidence of the process used to carry out the reviews and the outcomes achieved. DS0000021794.V337808.R01.S.doc Version 5.2 Page 12 Staff spoken to, appeared to be knowledgeable about the care needs of people they were caring for. One relative stated that she was satisfied with the care being provided to her father, as he had been helped to regain some of his mobility back. Only a few people living at the home were able to express their views independently. They said that the care they were receiving was good. A few others passed comments like “Staff are very good. They look after us well”. Relatives also stated that, in their view, staff treated their loved ones with respect and observed their dignity at all times. During the inspection, staff were observed in their interactions with people in their care and such interactions were friendly, polite and respectful. Most people who took part in our service user survey also confirmed this view. People living at the home, were found to be appropriately dressed and appeared to be receiving a good standard of personal care. A number of health care professionals were involved in providing additional support to some people who live at the home and care records confirmed their involvement. Relatives were satisfied that their loved ones were receiving the necessary help from their GP’s and other health care professionals like district and community nurses and consultants. In our survey for health professionals, a respondent commented that the standard of care at the home had improved and advised that staff should continue improving their communication with the local health services, for the benefit of the people using the service. The storage, handling and administration of medicines were checked. Although, medicines were securely stored in locked cupboards and trolleys, there was inadequate storage space. A number of items, including dressings and some medicines bottles were kept on the floor, as there was not enough shelf space. This could lead to mistakes in the handling of medicines. The receipt of medicines was also not appropriately recorded and this made it difficult to track the administration of medicines to people for whom they were prescribed. DS0000021794.V337808.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence, including a visit to the service. Opportunities for taking part in social and recreational activities were limited and this affected the quality of life of people who live at the home. EVIDENCE: During the inspection, a number of people, in each of the units, were observed sitting in the lounges for most of the day except when they were receiving personal care and at meal times. Others chose to stay in their own rooms. Some of the people, who spent their time in one lounge, were observed to be dozing off for fairly long periods, whilst the television was on. Most of the time, people were left on their own, as care staff undertook a series of tasks. Notice boards were seen along corridors, giving information on a range of items, like the day, date, the menu and the weather. There were no planned activities taking place, except for a bingo session, which was observed in one of the lounges. Staff were observed on occasions, to spend some time in the lounges, DS0000021794.V337808.R01.S.doc Version 5.2 Page 14 but their interactions with people using the service appeared very limited and related to certain tasks at hand. In discussion, staff stated that activities were usually planned by the activities co-ordinator. There was an activity book, in which any leisure and social activity undertaken by an individual was recorded. The inspector noted that entries about activities undertaken by some people, who live at the home, were infrequent and did not relate to any social care needs assessment and care plan. In one instance, the last recorded activity for an individual was dated over a month ago. One person said that there was nothing to do and that “ I am stuck here, day after day”. However, care staff said that they sometimes take her for a walk in the courtyard. One person said that she was pleased about her recent holiday she has had, in the company of staff. Staff also stated that various trips and outings had been organised for the people living at the home. In our service user survey, respondents commented on the lack of appropriate social stimulation, which appeared to be affecting their quality of life. Relatives also said that they would like to see more social stimulation for benefit their loved ones. Staff stated that routines were fairly flexible. They would assist people in their care to make some simple choices, for example, when to get up, what to wear and what to eat. Lunchtime was observed. This was the main meal of the day. It consisted of fish; fried or poached, with vegetables. There was an alternative if people wanted something else. Deserts and fruit drinks were also offered. Dining tables were not set with tablecloth and cutlery. Meals were served plated. It was noted that the seating in the dining area in each unit was rather limited. There were fewer seats than the number of people accommodated in the unit. Staff were noted to be assisting a number of people to eat their meals. This reduced further the space available and the dining areas appeared “crowded and noisy”. Staff explained that a number of people chose to eat in their own rooms. However, it was noted that in some instances, people who chose to have their meals in their rooms, did not have the use of an appropriate table to eat from. One person was happy to eat her meal in a tray, placed on her lap. Staff confirmed that an appropriate risk assessment had been undertaken to ensure the safety of the person concerned. DS0000021794.V337808.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. People living at the home were protected from harm and abuse. A complaints procedure was in place. However, it was not being appropriately implemented and therefore could not effectively contribute to the improvement of the service. EVIDENCE: There was a complaints procedure in place and it gave information on how to make a complaint. The procedure was included in the service user guide and copies of it were displayed in the home. A few people said they could tell a member of staff if they felt something worried them. Relatives said they were aware of the complaints procedure and would use it if necessary. However, they felt that they could express their concerns to staff, knowing that they would be addressed. The home had received eight complaints in the last twelve months. Records show that although, they were classed as old complaints, not all complaint investigations were satisfactorily concluded and therefore their outcomes were not clearly stated. DS0000021794.V337808.R01.S.doc Version 5.2 Page 16 An adult protection policy was also available to promote the safety and welfare of people living at the home. Information supplied by the registered manager indicated that the service was proactive in implementing its adult safeguarding procedures, thereby protecting people who live at the home. There had been four referrals to the adult safeguarding team of the local social services department in the last twelve months and they had been addressed. Staff spoken to, said that they had received training on adult safeguarding issues. They showed an understanding of the methods of identifying abuse and relevant steps to take in reporting any allegations. DS0000021794.V337808.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The home was well maintained and offered a safe and clean environment to people who live in it. However, the dining facilities were limited and failed to make meal times a more pleasant experience. EVIDENCE: The inspector, accompanied by a senior manager, undertook a tour of the premises. The main entrance to the building was accessible to wheelchair users. However, the call bell at the entrance door was placed at a level that hindered its use by wheelchair users. The accommodation was provided over two floors and there was a passenger lift to facilitate access between these floors. There were four separate units DS0000021794.V337808.R01.S.doc Version 5.2 Page 18 and each was accessible through a door, which was provided with a security lock in order to maintain the safety of people living at the home. Each unit had its own dining room, lounge and hygiene facilities. It was noted that the seating capacity of the dining rooms was limited due to their size and the dining furniture that they could accommodate. This meant that at meal times, the dining areas became ‘ crowded and noisy’ and did not offer a pleasant environment. One of the lounges was used as a smoking area, but it allowed smoke to drift along the corridors. The building appeared to be well maintained and all the units were in a good decorative state. The communal areas were clean and tidy. A few people using the service said that they liked their bedrooms. A few bedrooms were checked, with the permission of the occupants. They were found to be clean, well decorated and adequately furnished. However, in some instances, there were no headboards to the beds provided and this could affect the safety of people using them, in particular, where the beds were next to a wall. The secure garden area appeared tidy and appropriately maintained. It was accessible to people who wanted to use it. It was noted that the home had been successful in obtaining an improvement grant from the Department of Health, to improve its physical environment. Some proposals concerning this work had been discussed at a ‘ Residents and Relatives’ meeting and the work would start in due course. DS0000021794.V337808.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Sufficient numbers of trained and supervised staff were deployed to provide care and support to people using the service. Staff were appropriately recruited to ensure the safety and welfare of people who live at the home. EVIDENCE: On the day of this inspection, the registered manager was on study leave and a senior manager of the Company was overseeing the running of the home. There were fifty-nine people in residence within the four units. One person was noted to be receiving care on a one to one basis. A mix of nursing and care staff was deployed to each unit and the staffing level appeared to be sufficient to meet needs of the people living at the home. The duty rota was checked. It was noted that the deployment of staff was not always based on the dependency levels of people using the service. On some occasions, the level of nurse staffing hours would go down, irrespective of the number of people in residence or of their needs. DS0000021794.V337808.R01.S.doc Version 5.2 Page 20 Nurses spoken to, except one, said they were trained in general nursing. They had received training on ‘Dementia Care’. However, very few seemed to have received training on mental health care, either for adults or older people. Most care staff spoken to stated that they had completed their “ National Vocational Qualification” (NVQ) level 2 in Care. It was noted that nearly 50 of the care staff were qualified to NVQ level 2. Care staff stated that they had received training on a range of subjects. These included topics like ‘moving and handling, Food Hygiene, Health and Safety, Fire Safety and Adult Protection’. It was noted that staff had not received any training dedicated to Equality and Diversity. The home had a recruitment and selection policy, which included procedures for observing equal opportunities and anti-discriminatory practice. The files of two members of staff who had been more recently recruited were checked. They showed that appropriate procedures were followed and all preemployment checks, including disclosures from the Criminal Records Bureau (CRB), had been satisfactorily completed before the staff concerned started working at the home. DS0000021794.V337808.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The home was adequately managed on a day- to- day basis, which ensured the safety and welfare of people using the service. However, record keeping and quality assurance methods were not sufficiently robust and could hinder the general improvement of the service. EVIDENCE: Relatives and staff spoken to, commented favourably on the way the home was managed. The registered manager was seen as an experienced nurse and a good team leader. She was appropriately supported by administrative staff and by her line manager. DS0000021794.V337808.R01.S.doc Version 5.2 Page 22 The operations manager stated that staff had carried out a satisfaction survey and had sent sixty questionnaires to relatives and friends and sixty to people who live at the home. A survey was also carried out for staff and referring agencies. Ten relatives/friends and only one person living at the home returned their questionnaires. The response from the agencies and staff was also low. A copy of the results was seen. It did not specify the dates when the survey was conducted, except that it took place in 2007. The operations manager stated that she dealt with a few issues raised from the survey, in order to improve the service. The registered manager had submitted information about the use of other quality monitoring tools being used at the home. These included the audit of medicines, care plans and environmental checks. However, an examination of a sample of care plans and of some medicines administration records, indicate some weakness in the use of the quality assurance system. There were no records to show what the audits undertaken, had shown and they had not picked up inadequacies in these areas. Management at the home was administrating the personal allowances of a substantial number of people who live at the home. The administrator stated that the home had appointeeship for twenty-three people at the request of social workers and relatives. Their money was pooled in a bank account and the interest accrued was paid to each person concerned. There was a second bank account, which dealt with the personal allowances of people who live at the home. Records were kept with regards to income and expenditure, backed up with receipts, on each person’s account. However, it was noted that people at the home had no access to their personal allowances after office hours and over the weekends. The accounts of two people were checked. In one instance, it was noted that one person, supported by staff, had incurred substantial expenses, which was not fully backed by receipts. It was also questionable whether this expenditure was warranted. The administrator explained that the usual procedure had been overlooked on this occasion and was taking the necessary steps to rectify the situation. Health and safety measures were in place to make sure that all equipment, facilities and work practices were safe. Staff had received training on health and safety issues and also on fire safety. Health and safety measures were monitored on a monthly basis. DS0000021794.V337808.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 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 X 3 X 2 X X 3 DS0000021794.V337808.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Care planning must be improved to ensure that social care needs are appropriately addressed and that care provided is adequately recorded and reviewed. All medicines received at the home must be appropriately recorded so that their use can be more easily monitored. Social care needs of people living at the home must be more effectively catered for. The programme of social, recreational and therapeutic activities must take into account the preferences and capabilities of people using the service. Facilities in the dining rooms and the meals service must be reviewed and improved so that mealtimes are made more relaxed, pleasant and enjoyable for people who live at the home. (Previous timescale of 01/06/07 not met). The management of complaints must be improved, so that the relevant investigations are DS0000021794.V337808.R01.S.doc Timescale for action 23/11/07 2. OP9 13 23/11/07 3. OP12 16 23/11/07 4. OP15 16 23/11/07 5. OP16 22 23/11/07 Version 5.2 Page 25 appropriately concluded and recorded together with their outcomes. 6. OP24 16,23 Beds must be provided with appropriate headboards in order to make them more comfortable and safe for people who use them. Receipts for all expenditure incurred on behalf of people who use the service, must be kept at the home as soon after the transactions, as possible and be made available for audit and inspection. 23/11/07 7 OP35 16 23/11/07 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 4 5 Refer to Standard OP9 OP15 OP15 OP19 OP19 Good Practice Recommendations The storage areas for medicines should be reviewed and improved to ensure their safekeeping at all times. The menus should provide at least two different options for the protein part of meals, in addition to alternatives, in order to give more choice to people using the service. The service should make sure it can meet the cultural and dietary needs of all the people who live at the home. The call bell at the entrance door should be placed in a way that makes it accessible to wheelchair users. Steps should be taken to make sure that the smoke drifts from ‘smoking rooms’ are contained in and extracted from these areas, to comply with the new smoke free regulations and best practice. The registered manager should calculate the deployment of care staff on the basis of both the dependency of people using the service and the layout of the home. All care and nursing staff should be provided with specific training on ‘mental health issues in old age’ in order to improve skills and understanding on the subject and improve service provision. DS0000021794.V337808.R01.S.doc Version 5.2 Page 26 6 7 OP27 OP30 8 9 OP30 OP33 10 OP33 All staff should be provided with training on ‘Equality and Diversity’ issues to ensure that they are guided by best practice in this area. The registered manager should consider the use and involvement of advocates, when conducting user satisfaction surveys, in order to secure an independent view of the service on behalf of those who are unable to participate in such surveys. Audits and other quality assurance tools used should be appropriately recorded, together with the outcomes achieved and remedial action taken to improve the service. DS0000021794.V337808.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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