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Inspection on 11/09/07 for Lower Bowshaw View Nursing Home

Also see our care home review for Lower Bowshaw View Nursing Home for more information

This inspection was carried out on 11th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

People living in the home said that the care they were receiving was "fine" and "good". They made comments such as "when you press your buzzer the staff come, there`s no waiting" and "the staff are very efficient" and "the staff work very hard". Comments received from questionnaires and from talking to relatives were in the main positive and included some ideas for improvements. Relatives said: "Overall we have been really impressed with life at Lower Bowshaw View and have recommended it to a lot of other people. We think how lucky to have found such a lovely place so near to family" and "Management, administration and staff have been helpful and welcoming" and "Although mums not always compliant, the staff manage to care for her very well". Health professionals said, "The staff are always polite and helpful and the residents well cared for". The inspector observed that people were well dressed in clean clothes and had received a good standard of personal care. Care plans were in place for all. They set out all aspects of personal, social and health care needs and recorded the staff action required to ensure all identified needs were met. In the main people`s health care was monitored and access to health specialists was available. People and relatives confirmed that staff were always respectful towards them. People said they enjoyed the activities available at the home. Activities available included quizzes, musical bingo, chair exercise and manicures. People also spoke about their trips outside the home to the garden centre and how they enjoyed entertainers being brought into the home for musical evenings. People said that they had a choice of food and that the quality of food served was "well cooked with just the right amount" and " I always enjoy my food". There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. Training took place, to equip staff with the essential skills needed. Systems were checked and serviced to maintain a safe environment.

What has improved since the last inspection?

All of the requirements made at the previous inspection had been actioned, the provider, managers and staff are commended for this. People said that they were able to choose their rising and retiring times. All staff had received adult protection training to equip them with the knowledge and skill to deal with any potential allegations or incidents of abuse. Before they commenced duty all members of staff had completed Criminal Records Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) first checks. References had also been obtained. Staff supervision took place, to support and give guidance to staff on an individual basis. Fire exits were seen to be kept clear and electrical cleaning equipment was safe and fit for its purpose.

What the care home could do better:

People`s health care records, including medication administration records must be fully completed to ensure that people`s health and welfare is maintained and improved. All window restrictors must be in working order so that people`s safety is ensured. The cause of any unpleasant odour in the home should be identified and action taken to eliminate this. Staffing levels need to be considered so that people and relatives feel that everyone`s needs are being met. The responsible individual must carry out a monthly monitoring visit at the home and report upon any good practise and areas for improvements. To ensure peoples health and safety, all floors must be free of slipping hazards, where instructed by the fire service, fire doors must be kept locked, shut when not in use and fire alarms must be tested every week.

CARE HOMES FOR OLDER PEOPLE Lower Bowshaw View Nursing Home Low Edges Crescent Sheffield South Yorkshire S8 7LN Lead Inspector Sue Turner Key Unannounced Inspection 07:50 11 September 2007 th 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 DS0000021795.V337270.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. DS0000021795.V337270.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lower Bowshaw View Nursing Home Address Low Edges Crescent Sheffield South Yorkshire S8 7LN 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 237 2717 0114 237 5743 none Total West Limited Miss Jennifer Louise Gordon Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places DS0000021795.V337270.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One individual who is identified on the application for variation for registration dated 14/05/04 at 4.1 may be accommodated. The minimum age of 55 years must have been attainted by the individual before he can reside at the home. 9th August 2006 Date of last inspection Brief Description of the Service: Lower Bowshaw View is a purpose built nursing home, which provides single bedroom en-suite accommodation for 40 older people. It is located in a residential area of Sheffield with good access to public services and amenities. Accommodation is on two floors; the first floor is accessed by a lift. The home has six lounges and dining rooms, a garden area, and car parking facilities. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was also on display in the entrance hall. The manager confirmed that the range of fees from 1st April 2007 were £355 £520 per week. Additional charges included hairdressing and private chiropody. DS0000021795.V337270.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Sue Turner regulation inspector. This site visit took place between the hours of 7.50 am and 5:00 pm. Jenny Gordon is the manager and was present during the visit and the responsible individual; Shada Rashid was also present when feedback was given. Prior to the visit the registered manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, their relatives and any professionals involved in peoples care. The Commission for Social Care Inspection (CSCI) received seven questionnaires from people using the service, four from relatives and two from professionals. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to nine staff, four relatives and seven people living in the home. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in August 2006. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well: People living in the home said that the care they were receiving was “fine” and “good”. They made comments such as “when you press your buzzer the staff come, there’s no waiting” and “the staff are very efficient” and “the staff work very hard”. Comments received from questionnaires and from talking to relatives were in the main positive and included some ideas for improvements. Relatives said: DS0000021795.V337270.R01.S.doc Version 5.2 Page 6 “Overall we have been really impressed with life at Lower Bowshaw View and have recommended it to a lot of other people. We think how lucky to have found such a lovely place so near to family” and “Management, administration and staff have been helpful and welcoming” and “Although mums not always compliant, the staff manage to care for her very well”. Health professionals said, “The staff are always polite and helpful and the residents well cared for”. The inspector observed that people were well dressed in clean clothes and had received a good standard of personal care. Care plans were in place for all. They set out all aspects of personal, social and health care needs and recorded the staff action required to ensure all identified needs were met. In the main people’s health care was monitored and access to health specialists was available. People and relatives confirmed that staff were always respectful towards them. People said they enjoyed the activities available at the home. Activities available included quizzes, musical bingo, chair exercise and manicures. People also spoke about their trips outside the home to the garden centre and how they enjoyed entertainers being brought into the home for musical evenings. People said that they had a choice of food and that the quality of food served was “well cooked with just the right amount” and “ I always enjoy my food”. There was a complaints procedure and Adult Protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. Training took place, to equip staff with the essential skills needed. Systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? All of the requirements made at the previous inspection had been actioned, the provider, managers and staff are commended for this. People said that they were able to choose their rising and retiring times. All staff had received adult protection training to equip them with the knowledge and skill to deal with any potential allegations or incidents of abuse. Before they commenced duty all members of staff had completed Criminal Records Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) first checks. References had also been obtained. DS0000021795.V337270.R01.S.doc Version 5.2 Page 7 Staff supervision took place, to support and give guidance to staff on an individual basis. Fire exits were seen to be kept clear and electrical cleaning equipment was safe and fit for its purpose. 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. The summary of this inspection report can be made available in other formats on request. DS0000021795.V337270.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 DS0000021795.V337270.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided sufficient updated and relevant information to inform people about their rights and choices. Pre admission information ensured the home was able to meet peoples health, social and care needs. EVIDENCE: The homes Statement of Purpose and Service User Guide were available, both in the entrance hall, for anyone visiting the home and a copy was also in each persons room. These included useful information about the home and the services offered. Both the Statement of Purpose and Service User Guide had been updated accordingly. Professionals and staff from the home prior to admission taking place assessed people. This either took place at Lower Bowshaw View or at peoples own DS0000021795.V337270.R01.S.doc Version 5.2 Page 10 homes if they preferred. The manager said that assessments in hospitals were also possible if needed. A newly devised pre service assessment was completed by the managers or nursing staff to assess that the home were able to meet each persons individual needs. DS0000021795.V337270.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health, social and personal care needs were documented in the care plans and a range of health care professionals visited the home, which meant that individual needs could be met. Some medication procedures and one persons health care records did not fully protect people’s health and welfare. People and their relatives were complimentary about the way staff promoted their privacy and dignity. EVIDENCE: Three plans of care were checked. These contained specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. Staff were aware of the contents of care plans and were knowledgeable about peoples individual needs. DS0000021795.V337270.R01.S.doc Version 5.2 Page 12 The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People said that GP’s, dentist, opticians and chiropodists also visited the home as requested. People and/ or their relatives said they were involved in drawing up and reviewing the care plans. Staff were updating risk assessments and care plans on a monthly basis. Relatives said: “Staff have been very efficient, keep me well informed and are prompt to summon a GP when needed”. “When mum was ill earlier this year, we chose for her to remain at the home, as I believe she gets the best care here”. “The staff keep me well informed about any changes in mums health and are quick to respond to her needs”. One person seen was very frail. Staff said that she spent most of her time in bed. The bed was clean and the person looked very comfortable. A chart in the room should have recorded the person intake, output and pressure area care, however recordings were very infrequent and on the two days prior to the inspection visit, and the only record was of the person having one drink of tea. No information was recorded for the person between 6:45 am and 08:00 pm. Medicines were securely stored around the home in locked trolleys within locked cupboards. People spoken to said that staff administered their medication at appropriate times. There was evidence that managers and trained staff were auditing medication administration procedures, however there were some gaps in the medication administration records (MAR), which questioned the validity of the monitoring system. Controlled drugs (CD) were kept in a clinical room and within a double locking cabinet. Two staff signatures were recorded in the CD register and CD drugs checked tallied with the records. People and relatives spoken with, and via their questionnaires, confirmed that the carers treated them with respect and provided personal care and support in a way that maintained their dignity and privacy and was sensitive to their individual needs and wishes. People said that staff addressed them by the name that they preferred and from discussions it was obvious that carers had developed positive relationships with the individuals that they supported. Curtains were not provided to bathroom, toilet and en suite windows and although the glass was opaque, silhouettes could still be seen, which could be off putting to people using these facilities. DS0000021795.V337270.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): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A range of activities was on offer, which promoted choice and maintained interests. Meals served at the home were of a good quality and offered choice, which ensured people received a healthy balanced diet. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home were made to feel comfortable whilst visiting their loved one. One person said they preferred to spend most of their time in their room and that the staff respected their decision. DS0000021795.V337270.R01.S.doc Version 5.2 Page 14 People said that there were a number of activities at the home, which appealed to their preferences and abilities. Activities particularly enjoyed were chair exercise, ladies manicure, bingo and games. Comments from people included: “The activities are good but we could do with a bigger television screen in the lounge”. “We have a very good range of activities and entertainment”. One person showed the inspector the printed brochure, given to everyone, which described the activities available at the home for the month of September. Activities and outings were varied and plentiful and the brochure was colourful, informative and valued by the people living in the home. People said that the meals at the home were “ no problem”, “good”, “fine” and “the food is always served hot”. Two people said they would like to have more variety, as the menus were too repetitive. Everyone said that there were always two options to choose from and if these were not suitable “staff would always get you something else”. One relative said: “It would be better if the menu was on view for residents and family to see, as some people have memory problems and cannot say what they have eaten”. This was put to the manager who agreed it would be a good idea. People were able to bring personal items with them into the home. All of the bedrooms seen were individually personalised, spacious and homely. DS0000021795.V337270.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): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected. EVIDENCE: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall and bedrooms. This contained details of who to speak to at the home and informed the reader of who to contact outside of the home to make a complaint should they wish to do so. People said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. The home had received two complaints since the last inspection; each had been investigated by the registered manager and any appropriate action taken as necessary. CSCI had not received any complaints about the home. Staff spoken to were clear how to respond and record any complaints received. DS0000021795.V337270.R01.S.doc Version 5.2 Page 16 An adult protection procedure was in place. Staff had undertaken formal training on adult protection, which had equipped them with the skills needed to respond appropriately to any allegations. People spoken to said that they felt safe living at the home. Two relatives said: “In the 8 months that my father has been in the home we have not had any cause for concern and would recommend the home to other people”. “We have raised one concern to the manager and this was rectified”. DS0000021795.V337270.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): Standards 19, 24 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In the main people live in a well-maintained environment. Repair, refurbishment and hygiene work is necessary to ensure people live in safe, comfortable and hygienic surroundings. EVIDENCE: The home was clean and tidy. Lounge and dining areas were domestically furnished and a tour of the building identified that some areas of the home were in need of minor repair. A handy person was employed to help maintain the environment. Some homely touches were provided, however some communal rooms, bathrooms and toilets looked quite bare. DS0000021795.V337270.R01.S.doc Version 5.2 Page 18 Bedrooms checked were cosy and people said their beds were comfortable, bed linen was clean and in a good condition. Window restrictors were fitted to all windows, however in one first floor bedroom and its en suite the restrictors were broken, allowing the windows to open very wide, causing potential danger. In one persons bedroom the arm of the easy chair was badly ripped. This person stayed in their room most of the time and used the chair on a daily basis. On the day of the site visit the home smelt unpleasant, in certain areas. One relative said: “There is a slight smell at times on bedroom corridors and some rooms could do with decorating, especially the toilets”. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. DS0000021795.V337270.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): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff were not provided to meet the needs of people. Recruitment procedures promoted the protection of people and staff had completed training, including induction. EVIDENCE: Staff said that the dependency needs of people living in the home were such that they often felt that enough staff wasn’t provided. They said that a number of people required the assistance of two staff members due to their mobility problems; this obviously had an effect on the amount of time that could be spent with each person. Carers also had the responsibility of carrying out activities, which although they enjoyed, added to their tasks. Relatives surveyed and spoken to also raised concerns about staffing levels. They said: “Although people do not seem to suffer they could do with extra staff on weekends and bank holidays”. DS0000021795.V337270.R01.S.doc Version 5.2 Page 20 “It would be better if there were more carers who had a little spare time to spend just sitting with residents”. “My only concern about the home is that there should be more staff, they are always so busy”. The manager said that they were currently working with 4/5 carers and 2 qualified during the day and evening and at night time 2/3 carers and 1 qualified. The inspector checked the rotas and found that there was only 2 carers and 1 qualified on, for the majority of nights. The manager said that they were trying to recruit two night carers but this was proving difficult. Considering the dependency levels of the people living in the home the inspector believes the staffing levels to be at a minimum and discussed with the manager and provider the urgency to increase the levels to a more acceptable standard. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, Adult Protection, First Aid and Fire. Qualified staff had undertaken training in medication procedures and some other specialised topics for example diabetes, dietary supplements and Mental Health falls and restraint, delivered by the Sheffield Partnerships for Older Peoples Projects (POPP’s) team. Ten care staff had achieved NVQ Level 2 or above in care. A number of care staff had also commenced the training. This clearly met the required minimum of 50 of the staff team trained to NVQ Level 2 in Care. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Three staff files checked identified that the member of staff had received induction training when they commenced work. Three records of employment were checked. These included all of the required information including interview assessment, verification of identity, references, certificates of training, health checks and evidence of CRB and POVA check. Application forms fully recorded previous employment. DS0000021795.V337270.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): Standards 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager’s approach benefited people and staff. A quality assurance system and people, relative and staff meetings ensured that the home was run in the best interests of everyone. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. People’s health and safety had been put at risk, in some areas. EVIDENCE: The registered manager is experienced in the care of older people and has achieved the Registered Managers Award (RMA). DS0000021795.V337270.R01.S.doc Version 5.2 Page 22 Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. One relative said: “Management and administration staff have been very helpful and are very welcoming”. The last monthly monitoring report from the provider was dated 12.02.06. The inspector talked to the provider about this and the provider made a commitment to carry out an audit of the home, each month and provide the manager with a report of this. The managers had many ways in which to check out the quality of the service that they were providing. Regular staff, resident and relative meetings were arranged and a quality assurance questionnaire had been sent out to people involved with the home asking for their views. An analysis of the quality questionnaires had been completed; however there wasn’t any evidence that following this any action had been taken. The managers agreed that this should be the next step in order to raise the quality of the service provided. The home handles money on behalf of some people. This was checked for three people. Account sheets were kept, receipts were seen for all transactions and monies kept balanced with what was recorded on the account sheet. The inspector discussed with the manager and provider a more secure way of safe guarding people’s finances. Formal staff supervision, to develop, inform and support staff took place at regular intervals and staff said that they found this useful and beneficial. Equipment at the home was serviced and maintained. Fire records evidenced that fire alarm checks took place, but could sometimes miss a week, which was not in line with the fire services recommended “weekly” check. Staff said fire drill training took place on a regular basis. During the site visit a number of hazards were seen that could affect the safety of people in the home: • A hot water machine was in a dining room, where people were able to walk freely. The machine was extremely hot to touch and could have been easily knocked over. The manager was asked to assess this risk and the machine was removed. DS0000021795.V337270.R01.S.doc Version 5.2 Page 23 • A bathroom floor was left extremely wet by staff after they had assisted someone to shower. This caused the floor to be very slippery and the door to the bathroom was left unlocked making it easily accessible to people at the home. Two linen cupboards that had notices stating, ”Fire door keep locked shut when not in use,” had been left open. • DS0000021795.V337270.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable DS0000021795.V337270.R01.S.doc Version 5.2 Page 25 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 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 DS0000021795.V337270.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 12 Requirement Timescale for action 11/09/07 2. OP9 13 3. OP24 OP38 OP19 OP24 OP19 13 23 13 People’s health care records must be fully completed to ensure that they are receiving the care they have been assessed as needing. To ensure peoples health and 11/09/07 welfare, MAR sheets must be fully completed and signed at the time of medication administration. To ensure peoples safety, all 11/09/07 window restrictors fitted must be in working order. So that people are able to sit comfortably in their rooms the chair identified must be repaired or replaced. To ensure people health and well being the cause of unpleasant odour in the home must be found and action must be taken to eliminate this. Sufficient staff must be on duty at all times to ensure that peoples needs are being met. The responsible individual must carry out a monthly monitoring visit as detailed in Regulation 26 DS0000021795.V337270.R01.S.doc 4. 01/10/07 5. OP26 12 01/10/07 6. 7. OP27 OP33 18 26 11/09/07 01/10/07 Version 5.2 Page 27 8. 9. OP38 OP38 23 (4) (c) (v) 12 13 of the Care Homes Regulations. Following this visit a report must be forwarded to the home and be available for inspection. Fire alarms must be tested every week. To ensure peoples health and safety: All floors must be free of slipping hazards. Where instructed by the fire service, fire doors must be kept locked, shut when not in use. 11/09/07 11/09/07 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 OP10 OP12 OP15 OP19 OP33 Good Practice Recommendations Curtains or blinds should be provided to bathroom, toilet and en suite rooms to ensure that peoples privacy and dignity is maintained at all times. A television with a bigger screen should be provided in the lounge. There should be a menu board on display so that people living in and visiting the home are aware of the meals on offer. Communal areas, toilets and bathrooms should be made to look more homely and appealing. An analysis of the information provided from the quality questionnaires should be completed, so that any appropriate action can be taken to improve the quality of the service. DS0000021795.V337270.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000021795.V337270.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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