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Inspection on 25/05/05 for Merseybank Nursing Home

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

This inspection was carried out on 25th May 2005.

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

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

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

What the care home does well

Service users spoken with were complimentary about the efforts of the staff to make Merseybank an enjoyable place to live. Staff strive to meet the individual needs of the service users, and the service users are given the opportunity to exercise as much control over their lives as possible. However, some of the service users in this home are quite dependent and rely very much on the staff to act in their best interests. There is commitment towards the development of staff, with opportunities for staff to undertaken further training. Service users expressed satisfaction with their bedrooms and with the other facilities on offer at the home. There is a lively social and leisure programme, with activities arranged in the home and outings organised to places of interest.

What has improved since the last inspection?

The storage arrangements for information held about service users have been made more secure. There has been replacement of some worn furnishings in service user bedrooms. The records of staff details in respect of pre-employment checks has been improved and the training programme has been amended to ensure that night staff receive more frequent fire safety training.

What the care home could do better:

There must be further evidence that service users are encouraged to enter into a partnership for the planned care that is specific to them. This means that there needs to be documentary proof that service users (or their representatives, where appropriate) are fully consulted when care plans are developed and thereafter when reviews take place. A recent inspection by a CSCI pharmacist resulted in several requirements. The timescales for action have not yet expired, but the home must ensure that robust medication systems are put in place to ensure that the safety of service users is not compromised at any stage. The maintenance and servicing arrangements need to be improved. There are a number of routine maintenance tasks that need to be undertaken to ensure that service users live within a well-maintained environment. The registered provider needs to expedite arrangements to secure valid safety certification for the gas and electrical services. Certificates to support that these services are in a good state of repair have expired. Immediate requirements have been made following this inspection in respect of the gas and electrical services certification.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Merseybank Nursing Home Carriage Drive Hadfield Glossop SK14 7PH Lead Inspector Andrew Bailey Unannounced 25 May 2005 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 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 and Care Homes for Adults 18 – 65*. 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. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Merseybank Nursing Home Address Carriage Drive, Hadfield, Glossop, Derbyshire, SK14 7PH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01457 855175 Parkcare Homes (No.2) Limited Wendy Jayne Loughlin Care Home with Nursing 74 Category(ies) of Dementia (18), old age, not falling within any registration, with number other category (18), Physical Disability (38) of places Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 18 Elderly mentally ill, aged 55 years and over, 1 first level registered nurse throughout. 2. 18 Elderly physically infirm, aged 55 years and over, 1 first level registered nurse throughout. 3. 38 Young disabled aged between 18-55 years, 1 first level plus 1 first/second level registered. 4. The Home Manager to be supernumerary for 37.5 hours per week. Date of last inspection 18 March 2005 Brief Description of the Service: Merseybank Nursing Home is registered for the care of 74 service users with nursing and personal care needs (including up to 18 service users with Dementia and up to 38 youger adults with physical disability). Thie home situated in Hadfield, near to the town of Glossop. Service user accommodation is provided on three floors with passenger lift and staircase access provided. The home is divided into four separate units. The units are staffed separately. There are expansive gardens, including a patio area. Support services are in place from local GPs. Other health support services are accessed on request or as required. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the inspection was approximately 6 hours. A tour of the building took place. Discussions were held with five service users and five staff. There were no relatives available to speak with during the inspection. A number of records were examined, including care plans (as part of the case tracking process, which is used to facilitate assessment of the service from service users’ perspectives). An assessment was also made of progress by the registered persons to address requirements made at the previous inspection of this service. A CSCI pharmacist undertook a routine inspection of the medication systems on 11 April 2005. Several requirements were made as a result of this visit, but the timescales for action have not yet expired. These requirements have been incorporated into this report and action to meet the requirements will be assessed in full at the next inspection. What the service does well: Service users spoken with were complimentary about the efforts of the staff to make Merseybank an enjoyable place to live. Staff strive to meet the individual needs of the service users, and the service users are given the opportunity to exercise as much control over their lives as possible. However, some of the service users in this home are quite dependent and rely very much on the staff to act in their best interests. There is commitment towards the development of staff, with opportunities for staff to undertaken further training. Service users expressed satisfaction with their bedrooms and with the other facilities on offer at the home. There is a lively social and leisure programme, with activities arranged in the home and outings organised to places of interest. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6-10 and 18–21) (Standards 11–17) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37–43) Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. 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. Prospective service users have an opportunity to “test drive” the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 (and standard 2 - Adults 18-65yrs) Appropriate pre-admission procedures are in place to ensure that new service users are admitted on the basis of a full assessment of their needs. EVIDENCE: Assessment information was recorded in all service user care plan files examined at this inspection. The assessments were comprehensive and formed the basis for the development of care plans. Additional information had been provided by other agencies involved in the admission arrangements, such as social services. Service user/representative written information was not examined at this inspection, as this had met the standard at previous inspections of this service. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6-10 and 18 –21 (Adults 18-65) 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. Including their physical and emotional health needs. 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. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. Service users receive personal support in the way they prefer and require. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 7, 9, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 (and standards 6, 7, 10 and 18 - Adults 18-65yrs) There is insufficient evidence of the involvement of service users in the development and review of their care plans, so this does not show that the service user is a true partner in care. The documentary standards of care plan entries are generally satisfactory. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 10 EVIDENCE: On the whole the service user plans examined were well detailed and comprehensive. Whilst many were based on core care plans they had been individualised to reflect the needs of the individual. A range of risk assessments had been undertaken and documented, including tissue viability and nutrition. Risk assessments had been frequently reviewed, but the input of the service user or their representative (documented in some instances e.g. with the use of bedrails) was not always supported by their signature. This provided a lower level of evidence that agreement had been reached about the outcome of the risk assessment. From examination of records there was insufficient evidence of service user (and/or representative) involvement in the formulation of care plans, which had been derived from pre-admission assessments and the outcomes of risk assessments. Discussion with service users confirmed this finding, with none of the service users describing anything resembling a partnership approach to care planning. In essence, this means that whilst specific aspects of care, such as the use of bedrails, might be discussed with a service user, the individual care plans developed by staff are seemingly not routinely discussed and agreed with the service user or their representative. There is not an open and transparent system in place that encourages meaningful involvement of the service user (or their representative) in determining the care to be provided. Service users spoken with confirmed that staff were treating them with respect and upholding their right to privacy. It was not possible to meet with any relatives to gain a greater insight into the care received by those less able to speak for themselves. However, observation of the staff at work indicated that they were treating the service users with respect and in a kindly manner. A carer spoken with described the induction programme and this appeared to adequately prepare staff for their role. A requirement made at the last inspection in respect of the security of service user records had been addressed. (A CSCI pharmacist undertook a routine inspection of the medication systems on 11 April 2005. Several requirements were made as a result of this visit, but the timescales for action have not yet expired. These requirements have been incorporated into this report and will be assessed in full at the next inspection). Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 11 – 17 (Adults 18-65) are: 12. 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. Including opportunities for personal development. Service users engage in appropriate leisure activities. Service users maintain contact with family/ friends/ representatives and the local community as they wish. And have appropriate personal, family and sexual relationships. 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. 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15, 16 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 (and standards 12, 13, 15, 16 and 17 - Adults 18-65yrs) The social and leisure programme is well organised, providing stimulating and interesting opportunities for the service users. The meals are reported to be of a good standard with choice and variety on offer. EVIDENCE: A quiz was taking place during the afternoon of this inspection and the service users present seemed to be enjoying the session. Staff spoken with described the activities on offer at the home and it is apparent that a varied programme is arranged, which includes outside visits. Notice boards were one of the media used to advertise details of events. The activities coordinator maintains activity records relating to each service users and this further supports the individualised approach to this lifestyle aspect of care. A recent introduction has been Internet access for service users, sited in a dedicated area of the home. The clinical manager reported that some of the service users had undertaken short computer courses. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 12 A service user mentioned two recent trips out, one to Blackpool and another to Wigan. This service user was very complimentary about the social and leisure programme. Another service user spoken with had made a personal choice not to become very involved in the activities programme. A member of staff spoken with displayed a clear commitment to promoting the psychological aspects of the care delivered to the service users (from a social and leisure perspective), in addition to an appreciation of the individual physical health needs to be met. Feedback from staff and service users indicated that the visiting arrangements were open, with the opportunity for service users to see their visitors in private. A service user described the daily routines as flexible, as far as was realistic in the home. Menus were examined and it was apparent that there was variety and choice for the service users. Most of the service users expressed satisfaction with the standard of the food. Several bedrooms contained furniture brought in by the individual service user, supporting the approach that service users are encouraged to personalise their rooms. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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. Including neglect and selfharm. The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 (and standard 22 - Adults 18-65yrs) There is a complaints procedure in place, with evidence to support that any concerns are thoroughly investigated and acted upon. EVIDENCE: There was a requirement made at the last inspection in respect of verbal complaints. Speaking with staff and service users confirmed that verbal concerns are investigated and action taken. There has been a complaint of which CSCI has been made aware that has not yet been closed, relating to an ex-service user of the home. There was documentary evidence available to confirm that the organisation is acting in an appropriate manner to seek a resolution to the concerns. A further concern that CSCI was made aware of, relating to the components and payment of fees, has now been resolved. A member of staff spoken with was conversant with the complaints system, demonstrating that they would be able to suitably advise any service user or visitor who had concerns of how these could be channelled. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) 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. Shared spaces complement and supplement service users’ individual rooms. Service users have sufficient and suitable lavatories and washing facilities. Provide sufficient privacy and meet their individual needs. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. And lifestyles. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 and 26 (and standards 24, 26, 27, 29 and 30 - Adults 18-65yrs) There are some maintenance issues to address to ensure that service users not only live an attractive environment but are also assured that they are safe. EVIDENCE: A tour of the premises was made to evaluate the environment. A number of maintenance issues were apparent, which could either give a poor visual impression to service users and visitors, or could additionally be a direct or indirect health and safety concern. On the younger persons unit (YPD1) the decoration of the walls adjacent to the clinical store was in poor condition. Ceiling tiles in one of the bedrooms had water damage. Several of the metal radiator covers on this unit were rusting. The fire door had smashed glass and a rotten frame (this was scheduled for replacement). The bathroom was in need of refurbishment and was also in use Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 15 as a store for commodes and a screen at the time of this inspection. The assisted bathroom had a rusting toilet frame and another toilet had a rusted handrail adjacent to the pedestal - these were rough and could also not be cleaned adequately. The sluice had many of the wall tiles missing, rendering adequate cleaning difficult (infection control hazard). There was pipework in the dementia unit (dining room), which required either removing or boxing in (health & safety risk). The pipework was covered by a table at the time of the inspection. A waste contract has been set up for dressings (a requirement from the last inspection). Assessment and adjustment for height appropriateness of light cords and notice boards etc to assist wheelchair users (identified as a requirement at the last inspection) had not yet been completed. Several bedrooms had been re-furnished since the last inspection, demonstrating good practice in this respect by of the providers. The fire officer had visited the premises in March 2005 and the issues raised were currently being addressed, with most complete or nearing completion (timescale not expired). A requirement had been made at the last inspection for locks to be fitted to all service users private accommodation. This work had not been completed. However, there were examples of risk assessment processes (dementia unit) for the fitting of locks and the use of keys by service users. This demonstrated an example of an appropriate and measured approach to this subject. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 36 (Adults 18-65) are: 27. 28. 29. 30. • • • Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. 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. Service users benefit from clarity of staff roles and responsibilities. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30 (and standards 34 and 35 - Adults 18-65yrs) The recruitment processes in place promote the protection of the service users. There is an established training programme to equip staff with the knowledge and skills to undertake their roles. EVIDENCE: Personnel files were examined at this inspection and there was evidence that appropriate pre and post employment checks had been made. Discussions with staff confirmed that the induction procedures adequately prepared staff for their roles and that there was an on-going commitment towards further staff training. A previous requirement in respect of fire safety training had been scheduled into the training programme. Service users spoken with considered the staff to be competent. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 37 – 43 (Adults 18-65) are: 31. 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 a well run home and from competent and accountable management of the service. 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. Service users are confident their views underpin all self-monitoring, review and development by the home. 32. 33. 34. 35. 36. 37. 38. • The Commission considers standards 33, 35 and 38 (Older People) and Standards 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38 (and standards 39 and 42 - Adults 18-65yrs) There are maintenance and servicing deficiencies, which fail to provide evidence that the safety and welfare of the services users, staff and third party persons is being fully safeguarded. There are quality-monitoring processes in place, although the effectiveness of these in assuring quality is questionable given the current requirement to address the maintenance and servicing issues at the home. EVIDENCE: Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 18 There is evidence of visits to the home on behalf of the registered providers in accordance with Regulation 26, to provide an on-going assessment of the running of the home, independent of the local management. The registered manager stated that there was a system in place to seek the views of service users – quality questionnaire. The results are made available on the website and for display in the home. There had been no recent results to summarise within the written information made available to service users. A service user spoken with was not aware of the system to measure satisfaction at the home (but also stated that they would not be interested in using such a system). At the last inspection there had been inconsistencies identified with the accounting arrangements. These have now been resolved, with on-going audit provided with the support of the group internal auditor. Documentation was examined at this inspection to support that the previous issues had been addressed. Servicing documentation was examined at this inspection. There remain concerns about the electrical installation and gas services. Both were the subjects of requirements following the last inspection in March 2005. The registered manager stated that there is work outstanding on the electrical installation (the reason why a certificate has not been issued). There has been no apparent action since the last inspection to secure valid certification confirming that these services are of a safe and suitable standard. The electrical installation and gas safety certificates are out of date. Immediate requirements have been made following this inspection to provide evidence of certification of the electrical and gas services. Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 19 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 x 2 x 3 3 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 2 x x x x 2 x 2 Score Standard No 7 8 9 10 11 Score 2 3 1 3 x Standard No 27 28 29 30 x x 3 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x x MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 x 34 x 35 3 36 x 37 x 38 1 Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 20 yes Are there any outstanding requirements from the last inspection? 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 (1, 2) Requirement There must be evidence of service user/representative involvement in the drawing up of and review of care plans The registered person must ensure that all controlled drug cupboards are rigidly fixed to a wall or floor by means of at least two rag-bolts in compliance with The Misuse of Drugs (Safe Custody) Regulations 1973 Medication must be administered to one service user at a time. Medication must not be dispensed into medicine pots in advance of it being administered to the service user Where a variable dose is prescribed the actual dose administered must be recorded. This includes medications prescribed as a gradually increasing or decreasing dosage If instructions on the Medication Administration Record (MAR) chart are altered or clarified by a member of staff, they must be correct It must be clearly marked on the MAR chart if a medication printed Timescale for action 31 July 2005 01 August 2005 2. op9 13 (2) 3. op9 13 (2) 01 June 2005 4. op9 13 (2) 17 (1) (a) 01 June 2005 5. op9 13 (2) 17 (1) (a) 01 June 2005 6. op9 13 (2) 17 (1) (a) 01 June 2005 Page 21 Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 on it is not to be administered 7. op9 13 (2) Staff must only administer prescribed medication from pharmacy labelled containers. Strips of tablets must not be removed from the labelled box in which thay are supplied Medication for a service user must not be allowed to run out. If a supply of medication for a service user is unavailable, the home must obtain a new supply promptly The circumstances in which when required medication is to be administered must be made clear on the MAR chart or in the care plan Medication prescribed and labelled for one service user must not be administered to another service user Medication that is no longer needed must be returned to the pharmacy Staff must not transfer medication from one container to another The staff member administering the medication must sign the MAR chart. If carers apply creams they must be the one to sign the MAR chart, not the nurse A record must be made of all medication returned to the pharmacy. This includes tablets in the Monitored Dosage System There must be a system to prevent excess stocks of medication being ordered and obtained The pipework in the dementia unit dining room must be removed or boxed in The flaking walls in the corridor in YPD1 must be redecorated 01 June 2005 8. op9 13 (2) 01 June 2005 9. op9 13 (2) 17 (1) (a) 01 June 2005 10. op9 13 (2) 01 June 2005 01 July 2005 01 June 2005 01 July 2005 11. 12. 13. op9 op9 op9 13 (2) 13 (2) 13 (2) 17 (1) (a) 14. op9 13 (2) 17 (1) (a) 13 (2) 01 July 2005 01 July 2005 31 August 2005 31 July 2005 Page 22 15. op9 16. 17. op19 ya24 23 (2) 23 (2) Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 18. 19. 20. 21. 22. 23. 24. ya24 ya24 ya24 ya24 ya24 ya24 ya29 23 (2) 23 (2) 23 (2) 23 (2) 23 (2) 23 (2) 23 (2) 25. 26. op24 ya30 23 (2) 23 (2) 27. 28. op38 op38 23 (2) 23 (2) All water damaged ceiling tiles must be replaced/redecorated Rusting radiator covers must be replaced or repainted The bathroom in YPD1 must be refurbished/redecorated and not used for storage purposes The rusting toilet frame in YPD1 must be replaced The rusting toilet handrail in YPD1 must be replaced The damaged and rotten fire door on YPD1 must be replaced An assessment of the premises must be made to ensure that fittings and adaptations are suitably placed for residents to use them (timescale taken from previous inspection report) Locks must be provided to all bedroom doors (previous timescale of 31/12/04 not met) The wall tiles in the sluice on YPD1 must be replaced or an alternative washable surface must be provided (infection control risk) A valid gas safety certificate must be obtained A valid electrical installation certificate must be obtained 31 July 2005 31 July 2005 30 September 2005 31 July 2005 31 July 2005 30 June 2005 30 June 2005 31 July 2005 31 July 2005 Immediate Immediate 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 Good Practice Recommendations Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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 Merseybank Nursing Home DC52 C02 S25442 Merseybank Nursing Home V228174 250505 Stage 4.doc Version 1.30 Page 24 - 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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